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Cost effectiveness of a manual based coping strategy programme in promoting the mental health of family carers of people with dementia (the START (STrAtegies for RelaTives) study): a pragmatic randomised controlled trial |
Knapp M, King D, Romeo R, Schehl B, Barber J, Griffin M, Rapaport P, Livingston D, Mummery C, Walker Z, Hoe J, Sampson EL, Cooper C, Livingston G |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary The objective was to assess the cost-effectiveness of a manual-based coping strategy intervention, for family carers of people with dementia. The authors concluded that the STraAtegies for RelaTives coping intervention was a cost-effective addition to usual care, for carer outcomes over eight months. The study was well conducted and clearly reported. The authors' conclusion is appropriate, but further research is required to assess the long-term outcomes. Type of economic evaluation Cost-effectiveness analysis, cost-utility analysis Study objective The objective was to assess the cost-effectiveness of a manual-based coping strategy intervention, for family carers of people with dementia. Interventions The intervention consisted of eight psychological therapy sessions, as described in the STraAtegies for RelaTives (START) manual. Sessions were delivered to family carers over eight to 14 weeks, by supervised psychology graduates who did not have clinical qualifications. They were provided as an addition to usual care, which was the comparator. Usual care focused on the patient, rather than their carers. It could include medical, psychological, and other health and social care services, consistent with National Institute for Health and Care Excellence (NICE) guidelines. Location/setting UK/secondary care, at home. Methods Analytical approach:A cost-effectiveness analysis was completed alongside a pragmatic, multicentre randomised controlled trial. The time horizon was eight months. The authors stated that the analysis was conducted from a health and social care perspective. Effectiveness data:The trial was conducted in London and Essex, with 173 carers randomised to the START intervention, and 87 carers randomised to usual care. The effectiveness of the intervention was determined by depression, measured using the Hospital Anxiety and Depression Scale (HADS), and by health-related quality of life, measured using the EQ-5D questionnaire. Questionnaires were completed by carers before intervention and at four and eight months after randomisation. Monetary benefit and utility valuations:Societal preference weights were applied to each of the EQ-5D health states to produce health state utilities for each carer in the study. The social preference weights were from a UK population survey published in 1995. Measure of benefit:The health benefit was measured in quality-adjusted life-years (QALYs) and total HADS scores. Cost data:The analysis included the cost of the intervention and the carer's use of health and social care services, such as hospital attendances, therapy sessions, visits to social clubs and community services. Carers were asked to report their service use over the previous four months at the start, and four and eight months after randomisation. Intervention costs were calculated using data for the therapist and clinical psychologist time spent training and delivering the intervention, and included overheads. The unit costs, assigned to services and health professional time, were NHS Reference Costs, Personal Social Services Research Unit costs, and data from voluntary sector bodies. All costs were reported in 2009 to 2010 UK £. Analysis of uncertainty:Bootstrapping was used to estimate 95% confidence intervals around the cost estimates. Cost-effectiveness acceptability curves were constructed for the likelihood that the intervention was cost-effective over a range of values for the willingness to pay for an additional QALY or total HADS unit change. Sensitivity analyses were conducted to assess the effects of missing data, and to adjust the outcomes for initial imbalances. Results Including all costs and adjusting for initial variables, the START intervention cost £252 (95% CI -28 to 565) more than usual care and was associated with an incremental QALY gain of 0.042 (95% CI 0.015 to 0.071). For the HADS analysis, it cost £247 (95% CI 0 to 569) more than usual care, with a total HADS change of 2.10 (95% CI 0.51 to 3.75). The incremental cost-effectiveness ratio for the START intervention versus usual care was £6,000 per additional QALY, or £118 per unit change on the total HADS. At a willingness-to-pay threshold of £20,000 per QALY gained, the likelihood that the intervention was cost-effective was 93%. At a threshold of £500 per total HADS unit change, the likelihood that it was cost-effective was 95%. Authors' conclusions The authors concluded that the START coping intervention was a cost-effective addition to usual care, for carer outcomes over eight months. CRD commentary Interventions:The intervention was clearly described, and was selected in response to a request from NICE for research into psychological interventions for carers of patients with dementia. An appropriate comparator – usual care – was used, and a brief outline of the services included in usual care was reported. Effectiveness/benefits:The effectiveness measures and outcomes were clearly reported. The clinical trial appears to have been well conducted and the outcomes were appropriately adjusted for initial values and patient characteristics. The authors stated that the clinical outcomes were fully reported in another paper (see Other Publications of Related Interest). Costs:The resource use and the unit costs applied to each item were clearly and comprehensively reported, allowing the accurate reproduction of the analysis. The method used to measure carer resource use was associated with a risk of recall bias, as carers might not accurately recall their resource use over the previous four months. The impact of such bias on the results is unclear. Shorter recall periods would have reduced this risk. Appropriate UK sources were used for the costs. Analysis and results:An appropriate method of randomisation was used in the trial and the outcome assessors were blind to allocation; blinding of participants was not possible due to the nature of the intervention. An appropriate incremental analysis was conducted to assess cost-effectiveness. The time horizon was short and unlikely to accurately capture the impact of the intervention on long-term health outcomes and costs. The authors stated that these would be assessed in the future. The cost-effectiveness acceptability curves were useful for demonstrating the uncertainty around the cost-effectiveness results. As the analysis was based on UK health outcomes and costs, the results should be generalisable across the UK. Concluding remarks:The study was well conducted and clearly reported. The authors' conclusion is appropriate, but further research is required to assess the long-term outcomes. Funding Funded by the NIHR Health Technology Assessment programme, UK. Bibliographic details Knapp M, King D, Romeo R, Schehl B, Barber J, Griffin M, Rapaport P, Livingston D, Mummery C, Walker Z, Hoe J, Sampson EL, Cooper C, Livingston G. Cost effectiveness of a manual based coping strategy programme in promoting the mental health of family carers of people with dementia (the START (STrAtegies for RelaTives) study): a pragmatic randomised controlled trial. BMJ 2013; 347: f6342 Other publications of related interest Livingston G, Barber J, Rapaport P, Knapp M, Griffin M, King D, et al. Clinical effectiveness of a manual based coping strategy programme (START, STrAtegies for RelaTives) in promoting the mental health of family carers of people with dementia: pragmatic randomised controlled trial. BMJ 2013; 347: f6276. Indexing Status Subject indexing assigned by NLM MeSH Adaptation, Psychological; Adult; Aged; Aged, 80 and over; Anxiety /diagnosis /economics /etiology /prevention & Caregivers /education /psychology; Cost-Benefit Analysis; Dementia; Depression /diagnosis /economics /etiology /prevention & Female; Great Britain; Health Care Costs /statistics & Humans; Intention to Treat Analysis; Linear Models; Male; Manuals as Topic; Middle Aged; Psychological Tests; Psychotherapy /economics /methods; Quality of Life; Quality-Adjusted Life Years; Surveys and Questionnaires; Treatment Outcome; control; control; numerical data AccessionNumber 22013047492 Date bibliographic record published 08/11/2013 Date abstract record published 16/12/2013 |
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