Cost-effectiveness Of Different Interventions Research Articles

Understanding context of violence against healthcare through citizen science and evaluating the effectiveness of a co-designed code of conduct and of a tailored de-escalation of violence training in Eastern Democratic Republic of Congo and Iraq: a study protocol for a stepped wedge randomized controlled trial

BackgroundViolence against health care workers (HCWs) is a multifaceted issue entwined with broader social, cultural, and economic contexts. While it is a global phenomenon, in crisis settings, HCWs are exposed to exceptionally high rates of violence. We hypothesize that the implementation of a training on de-escalation of violence and of a code of conduct informed through participatory citizen science research would reduce the incidence and severity of episodes of violence in primary healthcare settings of rural Democratic Republic of Congo (DRC) and large hospitals in Baghdad, Iraq.MethodsIn an initial formative research phase, the study will use a transdisciplinary citizen science approach to inform the re-adaptation of a violence de-escalation training for HCWs and the content of a code of conduct for both HCWs and clients. Qualitative and citizen science methods will explore motivations, causes, and contributing factors that lead to violence against HCWs. Preliminary findings will inform participatory meetings aimed at co-developing local rules of conduct through in-depth discussion and input from various stakeholders, followed by a validation and legitimization process. The effectiveness of the two interventions will be evaluated through a stepped-wedge randomized-cluster trial (SW-RCT) design with 11 arms, measuring the frequency and severity of violence, as well as secondary outcomes such as post-traumatic stress disorder (PTSD), job burnout, empathy, or HCWs’ quality of life at various points in time, alongside a cost-effectiveness study comparing the two strategies.DiscussionViolence against HCWs is a global issue, and it can be particularly severe in humanitarian contexts. However, there is limited evidence on effective and affordable approaches to address this problem. Understanding the context of community distrust and motivation for violence against HCWs will be critical for developing effective, tailored, and culturally appropriate responses, including a training on violence de-escalation and a community behavioral change approach to increase public trust in HCWs. This study aims therefore to compare the effectiveness and cost-effectiveness of different interventions to reduce violence against HCWs in two post-crisis settings, providing valuable evidence for future efforts to address this issue.Trial registrationClinicalTrial.gov Identifier NCT05419687. Prospectively registered on June 15, 2022.

A contemporary review of the treatments and challenges associated with penile rehabilitation after radical prostatectomy including a proposed optimal approach.

Prostate cancer is one of the most prevalent malignancies affecting men worldwide. Despite advancements in understanding prostate anatomy and minimally invasive approaches to surgical treatment, surgery can have significant adverse effects on sexual function. Penile rehabilitation strategies have emerged as a promising approach to mitigate the impact of prostate cancer treatments on erectile function and improve quality of life. Several methods have been employed for penile rehabilitation, including pharmacotherapy, vacuum erection devices, intracavernous injections, and emerging novel techniques. Yet, there is no consensus on the exact programs or timing of initiation that should be utilized for optimal recovery after surgery. This review discusses various rehabilitation protocols and long-term outcomes and explores the cost-effectiveness of different interventions. Additionally, this review discusses the importance of a multidisciplinary approach to penile rehabilitation which includes patient education, counseling, and the selection of an appropriate rehabilitation strategy tailored to each individual's needs and preferences. Continued research and collaboration among healthcare professionals are essential to refine rehabilitation approaches and ensure optimal outcomes for patients with prostate cancer.

Economic evaluation of 27,540 patients with mood and anxiety disorders and the importance of waiting time and clinical effectiveness in mental healthcare

Understanding the drivers of health and economic cost for the treatment of mental health conditions is critical to meet the accelerating demands for care. We conducted an economic evaluation of real-world healthcare-systems data from 27,540 patients receiving care for a mood or an anxiety disorder within the UK National Healthcare Service. Using Markov models built on discrete health states to compare the cost-effectiveness of different interventions, we show that the principal drivers of healthcare cost relate to waiting times and treatment effectiveness. We find that internet-delivered cognitive behavioral therapy has a ‘dominant’ incremental cost-effectiveness ratio relative to standard care, offering similar clinical effectiveness but with shorter treatment times. In most healthcare systems, the clinical effectiveness of mental healthcare remains unquantified, and long treatment times are common. The potential for these findings to inform mental healthcare policy is substantial, particularly around immediacy of access and the importance of outcomes-focused quality management.

P073 Comparative effectiveness of different exercise interventions on central sensitisation indices in humans: A systematic review and network meta-analysis

Abstract Background/Aims Exercise has shown a promising effect in reducing central sensitisation (CS), but it is unknown which exercise type is the most effective. This review aimed to rank and compare the effectiveness of different exercise interventions on CS in people with or without chronic musculoskeletal pain. This will help to identify the optimal exercise intervention to improve pain by reducing CS for subsequent use in clinical trials. Methods We searched MEDLINE, EMBASE, AMED, CINAHL, SPORTDiscus, CENTRAL, PEdro, SCOPUS, as well as references cited in the selected papers, and grey literature from inception to February 2022. We included randomized controlled trials (RCTs) that assessed the effect of exercise interventions on CS indices in humans. RCTs where a specific effect of exercise could not be determined were excluded. Pairwise and network meta-analyses (frequentist and Bayesian) were conducted using random effects models. Effect sizes were calculated using standardized mean difference (SMD). P-score as well as SUCRA score were used to rank the exercise interventions (from best to worst) in both frequentist and Bayesian approaches, respectively. Results The search returned 93,657 records, of which 143 RCTs (5,362 participants [4890 participants had musculoskeletal pain (122 studies), and 427 were pain free (21 studies)]) were eligible. Firstly, we performed the pairwise meta-analysis to examine the effect of all exercise interventions on all CS outcomes. It showed moderate improvement of CS outcomes (SMD - 0.77, 95% confidence interval (95%CI) -0.89 to -0.65, I2 = 87%, p < 0.01). After that, 80 RCTs were included in the network meta-analysis (NMA) using inactive controls as a common comparator. In terms of efficacy at improving indices of CS, all exercise interventions were more effective than control. Combined strengthening and stretching exercise exhibited the highest probability to be the optimal intervention reducing CS (P-score: 0.8896, SUCRA score: 0.8719, SMD= -2.02, 95%CI: -2.83: -1.20), followed by strengthening, stretching and aerobic combination (P-score: 0.8557, SUCRA score: 0.8517, SMD = -1.92, 95%CI: -2.90: -0.95), and stretching with aerobic exercise (P-score: 0.7794, SUCRA score: 0.7198, SMD = -1.70, 95%CI: -2.79: -0.62). However, differences between these three interventions’ effect sizes were small, and 95% CI were overlapping. Other interventions included, mind body exercise, aerobic plus strengthening exercise, strengthening exercise, stretching exercise, aerobic exercise. Conclusion Our meta-analysis suggested that various exercise interventions are effective in improving CS. Multicomponent exercise tends to be the most effective, but some exercise combinations might be better than others. Strengthening and stretching combination shows the greatest likelihood among other combinations of being the optimal exercise type. These findings might have utility informing future treatment recommendations for people with CS features. However, Further research should be considered to explore cost-effectiveness of different interventions. Disclosure A.A. Abd Elkhabir: None. D.F. McWilliams: Grants/research support; grant support from Pfizer and Eli Lilly. S. Smith: None. W. Chaplin: None. M. Salimian: None. V. Georgopoulos: None. A. Kouraki: None. D.A. Walsh: Consultancies; Since 2015 DAW has undertaken consultancy through the University of Nottingham to AbbVie Ltd, Pfizer Ltd, Eli Lilly and Company, Love Productions,, Reckitt Benckiser Health Limited and GSK (each non-personal, pecuniary). Honoraria; He has contributed to educational materials through the University of Nottingham, supported by Medscape Education, New York,, International Association for the Study of Pain, and Osteoarthritis Research Society International (OARSI), each of which received financial support from commercial and non-commercial entities, (each non-personal, pecuniary).. Member of speakers’ bureau; He has received speaker fees from the Irish Society for Rheumatology (personal pecuniary).. Grants/research support; He has been responsible for research funded by Pfizer, Eli Lilly, UCB Pharma (non-personal, pecuniary). Other; He receives salary from the University of Nottingham, who have received funding for that purpose from Sherwood Forest Hospitals NHS Foundation Trust,, Nottingham University Hospitals NHS Trust and UKRI/Versus Arthritis (personal, pecuniary).

Cost Effectiveness of Physiotherapy Services for Chronic Condition Management: A Systematic Review of Economic Evaluations Conducted Alongside Randomized Controlled Trials

Purpose: To determine the cost-effectiveness of physiotherapy (PT) to manage individuals with chronic conditions. Method: Design: Systematic review of randomized controlled trials (RCTs). Eligibility: RCTs with adult participants diagnosed with ≥1 chronic condition, an intervention delivered or supervised by a physiotherapist, including an economic evaluation of the intervention provided. Procedure: Eight databases were searched. Title/abstract screening, full-text review, and data extraction were performed in duplicate. The quality of included studies was assessed using Cochrane's Risk of Bias Assessment 2.0. Results: Fifty-three articles were included in this review. Fifteen compared PT to no PT, 38 compared novel PT to conventional PT. Of the studies comparing PT to no PT, 53% found PT to be cost-effective. Of the studies comparing novel to conventional PT, 55% found novel interventions were cost-effective. Overall, PT was cost-effective in most studies related to arthritis, chronic LBP, and chronic neck pain. The heterogeneity of study characteristics limited the ability to perform a meta-analysis. Conclusions: Over half of included studies reported PT to be cost-effective. Future high quality RCTs performing rigorous economic evaluations are needed to determine the cost-effectiveness of different interventions delivered or supervised by a PT to prevent disability for those with chronic conditions.

Cost effectiveness of dietary interventions for individuals with mental disorders: A scoping review of experimental studies.

This scoping review aimed to explore the extent of the evidence of experimental studies evaluating the cost effectiveness of dietary interventions in individuals with mental disorders. Five databases (CINAHL, EMBASE, MEDLINE, PsycINFO and Scopus) were searched to October 2020 for cost-analysis studies of interventions aiming to improve dietary intake in people with mental disorders. No restriction was placed on participant age, mental disorder type or intervention design. Results are presented narratively. Of 2753 articles identified, 13 articles reporting on eight studies were included. Studies were RCTs (n=5), cluster RCT (n=1), cluster preference RCT (n=1), and pre-post test (n=1). Seven studies were in community settings (eg, outpatient clinics), and one study in the community housing setting. All studies were in adults, seven included male and female participants, and one included only females. Defined mental disorder diagnoses included serious/severe mental disorders (n=3), major depression (n=2), schizophrenia, schizoaffective disorder or first-episode psychosis (n=1), any mental disorder (n=1), and bulimia nervosa (n=1). Five interventions were multi-behaviour, two were diet only and one was eating disorder treatment. Cost analyses included cost-utility (n=3), cost-effectiveness (n=1), cost-utility and cost-effectiveness (n=3), and a costing study (n=1). Two studies (25%) reported positive results in favour of cost effectiveness, and four studies reported a mix of positive and neutral results. There is limited evidence evaluating the cost effectiveness of dietary interventions in individuals with mental disorders. Additional studies in various settings are needed to confirm cost effectiveness of different interventions.

Identifying the evidence base of interventions supporting mental health nurses to cope with stressful working environments: A scoping review.

To scope the evidence on interventions used to help mental health nurses cope with stressful working environments. Nursing managers may implement interventions to support mental health nurses cope in their role. However, the evidence supporting these interventions has not been recently reviewed. A scoping review was conducted which entailed searching and selecting potential studies, undertaking data extraction and synthesis. Eighteen studies published since 2000 were identified. They employed different designs, ten used quasi-experimental methods. Interventions involving active learning appeared beneficial, for example stress reduction courses and mindfulness. However, small sample sizes, short follow-up periods and variation in outcome measures make it difficult to identify the optimum interventions. No studies have considered cost-effectiveness. There is some evidence that mental health nurses benefit from interventions to help them cope with stressful working environments. However, higher quality research is needed to establish the effectiveness and cost-effectiveness of different interventions. Managers should provide opportunities and encourage mental health nurses to engage in active learning interventions, for example mindfulness to help them cope with stressful working environments. Nurses also want managers to address organisational issues; however, no research on these types of interventions was identified.

Cost-Effectiveness of Interventions for the Prevention and Control of COVID-19: A Systematic Review and Meta-Analysis

Background: The COVID-19 pandemic is an unprecedented global crisis and has a profound impact on health-care systems, society and economy. The cost-effectiveness of different interventions for the prevention and control of COVID-19 remains debated. We aimed to quantitatively summarize the health economic evaluation evidence of prevention and control programs addressing COVID-19 globally.Methods: We did a systematic review and meta-analysis to assess the economic and health benefit of interventions of COVID-19. We searched PubMed, Embase, Web of Science and Cochrane Library of economic evaluation from 31 December, 2019 to 13 July, 2021 to identify relevant literatures. Two researchers screened titles and abstracts, extracted data from full-text articles, and did quality assessment by the Consolidated Health Economic Evaluation Reporting Standards checklist. Meta-analyses were done using random-effects models to estimate pooled incremental net benefit (INB). Heterogeneity was assessed using I^2 statistics, and publication bias was assessed by Egger’s test. This study is registered with PROSPERO, CRD42021267475.Findings Of 15542 studies identified, 50 articles were included in the systematic review, and 17 articles (9 studies about non-pharmacological interventions (NPIs), 4 studies about vaccinations and 4 studies about treatments) were included in the meta-analysis. The pooled INB of NPIs, vaccinations and treatments were $972·05 (95% CI $772·52 to $1171·59), $295·18 (95% CI $209·58 to $380·77) and $14854·90 (95% CI $1783·60 to $27926·20), respectively. The pooled INBs in subgroups of screening, and suppression were $2390·89 (95% CI $1932·92 to $2848·85) and $2156·00 (95% CI $1114·40 to $3197·59). Sensitivity analyses showed similar findings.Interpretation: NPIs, vaccinations and treatments are all cost-effective in combating COVID-19 pandemic. However, evidence almost from high-income and middle-income countries, further studies from lower-income countries are needed.Funding: National Natural Science Foundation of China (No. 71910107004, 91746205, 72122001, 71934002).Declaration of Interest: The authors declare no competing interests.

The Economic Burden of Different Multiple Sclerosis Courses: Analysis from Italian Administrative and Clinical Databases

INTRODUCTION: Poor specific economic information are available for the different Multiple Sclerosis (MS) courses: relapsing remitting (RRMS), secondary progressive (SPMS) and primary progressive (PPMS). This study aims to fill this gap.METHODS: A cost of illness study was conducted. Clinical information of patients treated in a major MS Center located in Lombardy, in the period 2004-2010, were linked with administrative data of Lombardy Healthcare System. We assessed the mean cost per patient-year and its association with different MS characteristics.RESULTS: The study identified 869 patients (83.9% RRMS, 8.5% SPMS, 7.2% PPMS). RRMS reported the highest cost per patient-year with a mean of € 5,623 in Expanded Disability Status Scale (EDSS) 0-3, € 8,675 in EDSS 3.5-6.5, and € 7,451 in EDSS 7-9. The PPMS patients reported the lower annual mean cost per patient in all EDSS categories. The mul-tivariate analysis reported a significant association between cost per patient-year and EDSS categories, relapse and use of Disease Modifying Therapies but not to MS courses, age and sex.CONCLUSION: This study provides a complete picture of MS courses direct costs at the different disability levels. The results can help to better understand the burden of each MS courses and the cost-effectiveness of different interventions.

Determining optimal strategies for primary prevention of cardiovascular disease: systematic review, cost-effectiveness review and network meta-analysis protocol

BackgroundDespite recent improvements in the burden of cardiovascular disease (CVD) in the UK, deaths from CVD are relatively high compared with other high-income countries. An estimated 7 million people in the UK are living with CVD, and the healthcare cost is approximately £11 billion annually. In more than 90% of cases, the risk of a first heart attack is thought to be related to modifiable risk factors including smoking, poor diet, lipidemia, high blood pressure, inactivity, obesity and excess alcohol consumption. The aim of the study is to synthesise evidence for the comparative effectiveness and cost-effectiveness of different interventions for the primary prevention of CVD.MethodsWe will systematically search databases (for example, MEDLINE (Ovid), Embase (Ovid), Cochrane Library) and the reference lists of previous systematic reviews for randomised controlled trials that assess the effectiveness and cost-effectiveness of any form of intervention aimed at adult populations for the primary prevention of CVD, including but not limited to lipid lowering medications, blood pressure lowering medications, antiplatelet agents, nutritional supplements, dietary interventions, health promotion programmes, physical activity interventions or structural and policy interventions. Interventions may or may not be targeted at high-risk groups. Publications from any year will be considered for inclusion. The primary outcome will be all cause mortality. Secondary outcomes will be cardiovascular diseases related mortality, major cardiovascular events, coronary heart disease, incremental costs per quality-adjusted life years gained. If data permits, we will use network meta-analysis to compare and rank effectiveness of different interventions, and test effect modification of intervention effectiveness using subgroup analyses and meta-regression analyses.DiscussionThe results will be important for policymakers when making decisions between multiple possible alternative strategies to prevent CVD. Compared to results from existing multiple separate pairwise meta-analyses, this overarching synthesis of all relevant work will enhance decision-making. The findings will be crucial to inform evidence-based priorities and guidelines for policies and planning prevention strategies of CVD.Systematic review registrationPROSPERO CRD42019123940.

A Review of the Development and Application of Generic Preference-Based Instruments with the Older Population.

Older people (aged 65years and over) are the fastest growing age cohort in the majority of developed countries, and the proportion of individuals defined as the oldest old (aged 80years and over) living with physical frailty and cognitive impairment is rising. These population changes put increasing pressure on health and aged care services, thus it is important to assess the cost effectiveness of interventions targeted for older people across health and aged care sectors to identify interventions with the strongest capacity to enhance older peoples' quality of life and provide value for money. Cost-utility analysis (CUA) is a form of economic evaluation that typically uses preference-based instruments to measure and value health-related quality of life for the calculation of quality-adjusted life-years (QALYS) to enable comparisons of the cost effectiveness of different interventions. A variety of generic preference-based instruments have been used to measure older people's quality of life, including the Adult Social Care Outcomes Toolkit (ASCOT); Health Utility Index Mark 2 (HUI2); Health Utility Index Mark 3 (HUI3); Short-Form-6 Dimensions (SF-6D); Assessment of Quality of Life-6 dimensions (AQoL-6D); Assessment of Quality of Life-8 dimensions (AQoL-8D); Quality of Wellbeing Scale-Self-Administered (QWB-SA); 15 Dimensions (15D); EuroQol-5 dimensions (EQ-5D); and an older person specific preference-based instrument-the Investigating Choice Experiments Capability Measure for older people (ICECAP-O). This article reviews the development and application of these instruments within the older population and discusses the issues surrounding their use with this population. Areas for further research relating to the development and application of generic preference-based instruments with populations of older people are also highlighted.

How can we evaluate the cost-effectiveness of health system strengthening? A typology and illustrations

Health interventions often depend on a complex system of human and capital infrastructure that is shared with other interventions, in the form of service delivery platforms, such as healthcare facilities, hospitals, or community services. Most forms of health system strengthening seek to improve the efficiency or effectiveness of such delivery platforms. This paper presents a typology of ways in which health system strengthening can improve the economic efficiency of health services. Three types of health system strengthening are identified and modelled: (1) investment in the efficiency of an existing shared platform that generates positive benefits across a range of existing interventions; (2) relaxing a capacity constraint of an existing shared platform that inhibits the optimization of existing interventions; (3) providing an entirely new shared platform that supports a number of existing or new interventions. Theoretical models are illustrated with examples, and illustrate the importance of considering the portfolio of interventions using a platform, and not just piecemeal individual analysis of those interventions. They show how it is possible to extend principles of conventional cost-effectiveness analysis to identify an optimal balance between investing in health system strengthening and expenditure on specific interventions. The models developed in this paper provide a conceptual framework for evaluating the cost-effectiveness of investments in strengthening healthcare systems and, more broadly, shed light on the role that platforms play in promoting the cost-effectiveness of different interventions.

Cost-effectiveness of salt reduction to prevent hypertension and CVD: a systematic review.

To analyse and compare the cost-effectiveness of different interventions to reduce salt consumption. A systematic review of published cost-effectiveness analyses (CEA) and cost-utility analyses (CUA) was undertaken in the databases EMBASE, MEDLINE (PubMed), Cochrane and others until July 2016. Study selection was limited to CEA and CUA conducted in member countries of the Organisation for Economic Co-operation and Development (OECD) in English, German or French, without time limit. Outcomes measures were life years gained (LYG), disability-adjusted life years (DALY) and quality-adjusted life years (QALY). Relevant aspects in modelling were analysed and compared. Quality assessments were conducted using the Drummond and Jefferson/British Medical Journal checklist. OECD member countries. Mainly adults. Fourteen CEA and CUA were included in the review which analysed different strategies: salt reduction or substitution in processed foods, taxes, labelling, awareness campaigns and targeted dietary advice. Fifty-nine out of sixty-two scenarios were cost-saving. The incremental cost-effectiveness ratio in international dollars (Intl.$; 2015) was particularly low for taxes, a salt reduction by food manufacturers and labelling (303 900 Intl.$/DALY). However, only six studies analysed cost-effectiveness from a societal perspective and quality assessments showed flaws in conducting and a lack of transparency in reporting. A population-wide salt reduction could be cost-effective in prevention of hypertension and CVD in OECD member countries. However, comparability between study results is limited due to differences in modelling, applied perspectives and considered data.

Integration of Patients' Decision-Making in Cost-Effectiveness Analysis of Diabetes Interventions: A Simulation Study Using System Dynamics Modeling

Markov-based and discrete event simulation models are widely used in health economic analysis to estimate the long term effects of treatment on clinical and economic outcomes. However, none of them simultaneously integrate patients’ economic resources and their medical decision making in the simulation. This study applied systems dynamics modeling into cost-effectiveness analysis (CEA) of glycemic control treatment. It explored the nonlinear dynamic impacts of patients’ behavior on the cost effectiveness of different interventions to better understand the complexity of diabetes patients’ medical choices in the real world and their impacts on the clinical and economic consequences.Our results showed that the cost-effectiveness ratio varied with patients’ out-of-pocket payment threshold for health care. It suggests that patients’ decision making of cost-related non-adherence with medication should be considered while conducting CEA for treatment of complex chronic condition like diabetes.This study offers insight into the current dynamics of health care costs and outcomes. While providing a framework for CEA with integration of diabetes treatment adherence, it opens up ways of evaluate the complexity of health care for chronic condition in the real world.

Improving Control of Tuberculosis in Low-Burden Countries: Insights from Mathematical Modeling

Tuberculosis control and elimination remains a challenge for public health even in low-burden countries. New technology and novel approaches to case-finding, diagnosis, and treatment are causes for optimism but they need to be used cost-effectively. This in turn requires improved understanding of the epidemiology of TB and analysis of the effectiveness and cost-effectiveness of different interventions. We describe the contribution that mathematical modeling can make to understanding epidemiology and control of TB in different groups, guiding improved approaches to public health interventions. We emphasize that modeling is not a substitute for collecting data but rather is complementary to empirical research, helping determine what are the key questions to address to maximize the public-health impact of research, helping to plan studies, and making maximal use of available data, particularly from surveillance, and observational studies. We provide examples of how modeling and related empirical research inform policy and discuss how a combination of these approaches can be used to address current questions of key importance, including use of whole-genome sequencing, screening and treatment for latent infection, and combating drug resistance.

Multimorbidity: What do we know? What should we do?

Multimorbidity, which is defined as the co-occurrence of two or more chronic conditions, has moved onto the priority agenda for many health policymakers and healthcare providers. Patients with multimorbidity are high utilizers of healthcare resources and are some of the most costly and difficult-to-treat patients in Europe. Preventing and improving the way multimorbidity is managed is now a key priority for many countries, and work is at last underway to develop more sustainable models of care. Unfortunately, this effort is being hampered by a lack of basic knowledge about the aetiology, epidemiology, and risk factors for multimorbidity, and the efficacy and cost-effectiveness of different interventions. The European Commission recognizes the need for reform in this area and has committed to raising awareness of multimorbidity, encouraging innovation, optimizing the use of existing resources, and coordinating the efforts of different stakeholders across the European Union. Many countries have now incorporated multimorbidity into their own healthcare strategies and are working to strengthen their prevention efforts and develop more integrated models of care. Although there is some evidence that integrated care for people with multimorbidity can create efficiency gains and improve health outcomes, the evidence is limited, and may only be applicable to high-income countries with relatively strong and well-resourced health systems. In low- to middle-income countries, which are facing the double burden of infectious and chronic diseases, integration of care will require capacity building, better quality services, and a stronger evidence base.

Sedation versus general anaesthesia for provision of dental treatment to patients younger than 18 years.

A significant proportion of children have caries requiring restorations or extractions, and some of these children will not accept this treatment under local anaesthetic. Historically this has been managed by the use of a general anaesthetic in children; however, use of sedation may lead to reduced morbidity and cost. The aim of this review was to compare the efficiency of sedation versus general anaesthesia (GA) for provision of dental treatment to children and adolescents younger than 18 years. This review was originally published in 2009 and was updated in 2012 and again in 2015. We will evaluate morbidity and effectiveness of sedation versus GA for provision of dental treatment to patients younger than 18 years. If data become available, we will analyse the cost-effectiveness of different interventions. If data are not available, we will obtain crude estimates of cost.Morbidity can be defined as 'an undesired result or complication'. For the purposes of this review, 'postoperative morbidity' refers to undesired results or complications such as nausea following a procedure, once the patient had been restored to consciousness and could breathe unaided. 'Intraoperative morbidity' refers to any complications that occur during the procedure that may necessitate action by the anaesthetist or the sedationist, such as respiratory arrest. In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 7); MEDLINE Ovid SP (1950 to July 2015); EMBASE Ovid SP (1974 to July 2015); System for Information on Grey Literature in Europe (SIGLE) (1980 to October July 2012); Latin American & Caribbean Health Sciences Literature (LILACS) (1982 to July 2015); and Institute for Scientific Information (ISI) Web of Science (1945 to July 2015).We also carried out handsearching of relevant journals to July 2015. We imposed no language restriction. We planned to include randomized controlled clinical trials that compared sedative agents versus general anaesthesia in children and adolescents up to 18 years of age undergoing dental treatment. We excluded complex surgical procedures and pseudo-randomized trials. Two review authors assessed titles and abstracts for inclusion in the review. We recorded information relevant to objectives and outcome measures by using a specially designed 'data extraction form'. We will employ the Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) approach to interpret findings. In our original review, we identified 16 studies for potential inclusion after searching available databases and screening titles and abstracts. After retrieving full-text studies, we found none to be eligible. We identified no additional studies in the updated search of July 2012. We identified two studies for possible inclusion in the updated search of July 2015; again we found these to be ineligible. Randomized controlled studies comparing use of dental general anaesthesia versus sedation are needed to quantify differences such as morbidity and cost.

Interventions for fatigue in peripheral neuropathy.

Persistent feelings of fatigue (or subjective fatigue), which may be experienced in the absence of physiological factors, affect many people with peripheral neuropathy. A variety of interventions for subjective fatigue are available, but little is known about their efficacy or the likelihood of any adverse effects for people with peripheral neuropathy. To assess the effects of drugs and physical, psychological or behavioural interventions for fatigue in adults or children with peripheral neuropathy. On 5 November 2013, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, EMBASE, CINAHL Plus, LILACS and AMED. We also searched reference lists of all studies identified for inclusion and relevant reviews, and contacted the authors of included studies and known experts in the field to identify additional published or unpublished data. We also searched trials registries for ongoing studies. We considered for inclusion randomised controlled trials (RCTs) and quasi-RCTs comparing any form of intervention for fatigue management in adults with peripheral neuropathy with placebo, no intervention or an alternative form of intervention for fatigue. Interventions considered included drugs, pacing and grading of physical activity, general or specific exercise, compensatory strategies such as orthotics, relaxation, counselling, cognitive and educational strategies. Two review authors independently assessed risk of bias and extracted study data. We contacted study authors for additional information. We collected information on adverse events from the included trials. The review includes three trials, which were all at low risk of bias, involving 530 people with peripheral neuropathy. The effects of amantadine from one randomised, double-blind, placebo-controlled, cross-over trial comparing amantadine with placebo for the treatment of fatigue in 80 people with Guillain-Barré syndrome (GBS) were uncertain for the proportion of people achieving a favourable outcome six weeks post-intervention (odds ratio (OR) 0.56 (95% confidence interval (CI) 0.22 to 1.35, N = 74, P = 0.16). We assessed the quality of this evidence as low. Two parallel-group randomised double-blind, placebo-controlled trials comparing the effects of two doses of ascorbic acid with placebo for reducing fatigue in adults with Charcot-Marie-Tooth disease type 1A (CMT1A) showed that the effects of ascorbic acid at either dose are probably small (standardised mean difference (SMD) -0.12 (95% CI -0.32 to 0.08, n = 404, P = 0.25)) for change in fatigue after 12 to 24 months (moderate quality evidence). Neither ascorbic acid study measured fatigue at four to 12 weeks, which was our primary outcome measure. No serious adverse events were reported with amantadine. Serious adverse events were reported in the trials of ascorbic acid. However,risk of serious adverse events was similar with ascorbic acid and placebo. One small imprecise study in people with GBS showed uncertain effects of amantadine on fatigue. In two studies in people with CMT1A there is moderate-quality evidence that ascorbic acid has little meaningful benefit on fatigue. Information about adverse effects was limited, although both treatments appear to be well tolerated and safe in these conditions.There was no evidence available from RCTs to evaluate the effect of other drugs or other interventions for fatigue in either GBS, CMT1A or other causes of peripheral neuropathy. The cost effectiveness of different interventions should also be considered in future randomised clinical trials.

Cost-effectiveness of interventions for increasing the possession of functioning smoke alarms in households with pre-school children: a modelling study.

BackgroundThe UK has one of the highest rates for deaths from fire and flames in children aged 0–14 years compared to other high income countries. Evidence shows that smoke alarms can reduce the risk of fire-related injury but little exists on their cost-effectiveness. We aimed to compare the cost effectiveness of different interventions for the uptake of ‘functioning’ smoke alarms and consequently for the prevention of fire-related injuries in children in the UK.MethodsWe carried out a decision model-based probabilistic cost-effectiveness analysis. We used a hypothetical population of newborns and evaluated the impact of living in a household with or without a functioning smoke alarm during the first 5 years of their life on overall lifetime costs and quality of life from a public health perspective. We compared seven interventions, ranging from usual care to more complex interventions comprising of education, free/low cost equipment giveaway, equipment fitting and/or home safety inspection.ResultsEducation and free/low cost equipment was the most cost-effective intervention with an estimated incremental cost-effectiveness ratio of £34,200 per QALY gained compared to usual care. This was reduced to approximately £4,500 per QALY gained when 1.8 children under the age of 5 were assumed per household.ConclusionsAssessing cost-effectiveness, as well as effectiveness, is important in a public sector system operating under a fixed budget restraint. As highlighted in this study, the more effective interventions (in this case the more complex interventions) may not necessarily be the ones considered the most cost-effective.

Increasing participation in cervical cancer screening: Offering a HPV self‐test to long‐term non‐attendees as part of RACOMIP, a Swedish randomized controlled trial

RACOMIP is a population-based, randomized trial of the effectiveness and cost-effectiveness of different interventions aimed at increasing participation in a well-run cervical cancer screening program in western Sweden. In this article, we report results from one intervention, offering non-attendees a high-risk human papillomavirus (HPV) self-test. Comparison was made with standard screening invitation routine or standard routine plus a telephone call. Women (8,800), aged 30-62, were randomly selected among women without a registered Pap smear in the two latest screening rounds. These women were randomized 1:5:5 to one of three arms: 800 were offered a high-risk HPV self-test, 4,000 were randomized to a telephone call (reported previously) and 4,000 constituted a control group (standard screening invitation routine). Results were based on intention to treat analysis and cost-effectiveness was calculated as marginal cost per cancer case prevented. The endpoint was the frequency of testing. The total response rate in the self-testing arm was 24.5%, significantly higher than in the telephone arm (18%, RR 1.36, 95% CI 1.19-1.57) and the control group (10.6%, RR 2.33, 95% CI 2.00-2.71). All nine women who tested positive for high-risk HPV attended for a cervical smear and colposcopy. From the health-care sector perspective, the intervention will most likely lead to no additional cost. Offering a self-test for HPV as an alternative to Pap smears increases participation among long-term non-attendees. Offering various screening options can be a successful method for increasing participation in this group.