Cost-Effectiveness of Collaborative Care for Depression in UK Primary Care: Economic Evaluation of a Randomised Controlled Trial (CADET)

Background

Collaborative care is an effective treatment for the management of depression but evidence on its cost-effectiveness in the UK is lacking.

Aims

To assess the cost-effectiveness of collaborative care in a UK primary care setting.

Methods

An economic evaluation alongside a multi-centre cluster randomised controlled trial comparing collaborative care with usual primary care for adults with depression (n = 581). Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER) were calculated over a 12-month follow-up, from the perspective of the UK National Health Service and Personal Social Services (i.e. Third Party Payer). Sensitivity analyses are reported, and uncertainty is presented using the cost-effectiveness acceptability curve (CEAC) and the cost-effectiveness plane.

Results

The collaborative care intervention had a mean cost of £272.50 per participant. Health and social care service use, excluding collaborative care, indicated a similar profile of resource use between collaborative care and usual care participants. Collaborative care offered a mean incremental gain of 0.02 (95% CI: –0.02, 0.06) quality-adjusted life-years over 12 months, at a mean incremental cost of £270.72 (95% CI: –202.98, 886.04), and resulted in an estimated mean cost per QALY of £14,248. Where costs associated with informal care are considered in sensitivity analyses collaborative care is expected to be less costly and more effective, thereby dominating treatment as usual.

Conclusion

Collaborative care offers health gains at a relatively low cost, and is cost-effective compared with usual care against a decision-maker willingness to pay threshold of £20,000 per QALY gained. Results here support the commissioning of collaborative care in a UK primary care setting.     

Effect of hypoproteinemia on lung fluid balance in awake newborn lambs

To study the influence of plasma protein concentration on fluid balance in the newborn lung, we measured pulmonary arterial and left atrial pressures, lung lymph flow, and concentrations of protein in lymph and plasma of eight lambs, 2-3 wk old, before and after we reduced their plasma protein concentration from 5.8 +/- 0.3 to 3.6 +/- 0.6 g/dl. Each lamb underwent two studies, interrupted by a 3-day period in which we drained protein-rich systemic lymph through a thoracic duct fistula and replaced fluid losses with feedings of a protein-free solution of electrolytes and glucose. Each study consisted of a 2-h control period followed by 4 h of increased lung microvascular pressure produced by inflation of a balloon in the left atrium. Body weight and vascular pressures did not differ significantly during the two studies, but lung lymph flow increased from 2.6 +/- 0.1 ml/h during normoproteinemia to 4.1 +/- 0.1 ml/h during hypoproteinemia. During development of hypoproteinemia, the average difference in protein osmotic pressure between plasma and lymph decreased by 1.6 +/- 2 Torr at normal left atrial pressure and by 4.9 +/- 2.2 Torr at elevated left atrial pressure. When applied to the Starling equation governing microvascular fluid balance, these changes in liquid driving pressure were sufficient to account for the observed increases in lung fluid filtration; reduction of plasma protein concentration did not cause a statistically significant change in calculated filtration coefficient. Protein loss did not influence net protein clearance from the lungs nor did it accentuate the increase in lymph flow associated with left atrial pressure elevation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Fluxes of methane and carbon dioxide from a small productive lake to the atmosphere

The fluxes of CH₄ and CO₂ to the atmosphere, and the relative contributions of ebullition and molecular diffusion, were determined for a small hypertrophic freshwater lake (Priest Pot, UK) over the period May to October 1997. The average total flux of CH₄ and CO₂ (estimated from 7 sites on the lake) was approximately 52 mmol m^–2 d^–1 and was apportioned 12 and 40 mmol m^–2 d^–1 toCH₄ and CO₂ respectively. Diffusion across the air-water interface accounted for the loss of 0.4and 40 mmol m^–2 d^–1 of CH₄ and CO₂ respectively whilst the corresponding figures for ebullition losses were 12.0 (CH₄) and 0.23 (CO₂) mmol m^–2 d^–1. Most CH₄ (96%) was lost by ebullition, and most CO₂ (99%) by diffusive processes. The ebullition of gas, measured at weekly intervals along a transect of the lake, showed high spatial and temporal variation. The CH₄ content of the trapped gas varied between 44 and 88% (by volume) and was highest at the deepest points. Pulses of gas ebullition were detected during periods of rapidly falling barometric pressure. Therelevance of the measurements to global estimates ofcarbon emission from freshwaters are discussed.     

Arterial Expression of the Calcium-Sensing Receptor Is Maintained by Physiological Pulsation and Protects against Calcification

Vascular calcification (VC) is common in chronic kidney disease (CKD) and contributes to cardiovascular mortality. The calcium-sensing receptor (CaSR) is present in human artery, senses extracellular calcium and may directly modulate VC. Objective: to investigate the association between arterial cyclic strain, CaSR expression and VC. Methods and Results: human aortic smooth muscle cells (HAoSMC) were cultured under static or strained conditions, with exposure to CaSR agonists, the calcimimetic R568, and after CaSR silencing and over-expression. High extracellular calcium reduced CaSR expression and promoted osteochondrogenic transformation and calcium deposition. This was partially prevented by cyclic strain and exposure to R568. CaSR silencing enhanced calcification and osteochondrogenic transformation, whereas CaSR over-expression attenuated this procalcific response, demonstrating a central role for the CaSR in the response to cyclic strain and regulation of VC. In arterial explants from CKD patients (n = 11) and controls (n = 9), exposure to R568 did not significantly alter calcium deposition, osteochondrogenic markers or total artery calcium content. Conclusions: physiological mechanical strain is important for arterial homeostasis and may protect arteries from VC. The beneficial effects of cyclic strain may be mediated via the CaSR.     

Effects of predation-risk on habitat use by Himalayan Snowcocks

Summary When given a choice, animals often prefer foraging habitats where predation risk is low, even if such habitats provide reduced foraging opportunities. We evaluated foraging rates of tame but free-ranging Himalayan Snowcocks (Tetraogallus himalayensis) in 16 types of alpine habitats. Foraging rate was highest on level or slightly-sloping terrain and where grasses were relatively abundant. We also observed 102 wild snowcocks and found they were most nervous about raptorial predators when on level or slightly-sloping terrain and in small coveys. Snowcocks face a dilemma: they are most vulnerable to raptors in areas where they can forage most efficiently. During summer snowcocks trade off higher foraging efficiency on level terrain for lower predation risk on steeper terrain. During winter, when raptor numbers are lower, snowcocks apparently revert to using level or slightly-sloping, high-efficiency foraging habitats. Risk of predation plays an important role in habitat selection and resource utilization by snowcocks.     

Counting error in the line-intercept method of measuring root length

The line-intercept method is widely used to estimate the length of roots washed from soil samples. Human error in root length estimates has not been quantified and is needed for error analysis and specification of training/testing requirements for new workers. Nine or ten individuals counted four samples of roots on each of five days. One sample was counted on each of the days to test day-to-day variation. A coefficient of variation of 10% was typically obtained for estimates of the length of a single sample by the counters. An uncertainty of about 7% resulted from differences in how a sample was arranged on the grid and how the counters varied as a group from day-to-day. Certain individuals tended to yield estimates appreciably higher or lower than the entire group, so new workers must be adequately evaluated.     

Measurement of the water potential of stored potato tubers

A method of measuring the water potential of stored potato tubers (Solanum tuberosum L.) was needed to investigate the relationship of bacterial soft rot in tubers to water potential. Pressure chamber measurements, while useful for tubers with functional stolons, cannot be made on stored tubers. Measurements could be made on excised tissue pieces in a hygrometer chamber and with hygrometers implanted into tubers. We report here our evaluation of these hygrometric methods using a comparison with the pressure chamber on tubers harvested with stolons intact.

In tubers of high water potential, measurements on excised tissue were as much as 0.5 megapascals lower than the pressure chamber, probably due to turgor-driven expansion of the sample when freed from constraints imposed by surrounding tissue. Good agreement (±0.05 megapascals) was found between the implanted hygrometer and the pressure chamber at potentials higher than −0.5 megapascals. At lower water potentials, both hygrometer measurements were higher than the pressure chamber. Respirational heating of the tissue contributed to the increase in the excised tissue samples, but not with the implanted hygrometers because of the hygrometer design. The osmotic pressure balanced the pressure chamber measurement of potential at −0.7 megapascals, but was too small to do so at lower potentials. At most, 25% of this discrepancy can be accounted for by dilution by apoplastic water. We believe that the pressure chamber measurement is too low at low water potentials and that the error is associated with air bubbles in the xylem. At low potentials air emerged from xylem vessels along with sap, and fewer xylem emitted sap as potentials decreased.