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Background/Objectives: Polygenic risk scores (PRSs) have been extensively studied and are increasingly applied in healthcare. One of the most studied and developed areas is predictive medicine for breast cancer, but there is no wider consensus on the indications for the clinical use of PRSs for breast cancer. This current guidance endeavours to articulate the scientific evidence underpinning the clinical utility of PRSs in stratifying breast cancer risk, with a particular emphasis on clinical application.

Methods: This guidance has been prepared by a group of experts who have been active in breast cancer PRS research and development, combining a review of the evidence base with expert opinion for indications for clinical use.

Results: Based on data from various studies and existing breast cancer prevention and screening services, the indications for clinical use of breast cancer PRSs can be divided into the following scenarios: (1) Management of cancer-free women with a family history of cancer; (2) individual personalised breast cancer prevention and screening in healthcare services; and (3) breast cancer screening programs for more personalised screening.

Conclusions: The integration of PRSs into clinical practice enables healthcare providers to deliver more accurate risk assessments, personalised prevention strategies, and optimised screening programmes, thereby improving patient outcomes and enhancing the effectiveness of breast cancer care. PRS testing represents a novel component in clinical breast cancer risk assessment, supporting a personalised, risk-based approach to breast cancer prevention and screening.

Introduction: Health and social care systems are constantly undergoing major reforms to meet the rising demands of an increasing proportion of older patients, with many such reforms aiming to improve integration and coordination. The aim of this systematic review was to synthesize the evidence on inter-organizational coordination interventions between hospitals and outpatient (health- and social care) providers for older patients with complex needs during- and after hospital discharge.

Methods: A systematic search of four databases was performed to identify interventions of inter-organizational coordination at hospital discharge for older patients with complex needs. The retrieved literature was analyzed using a narrative synthesis.

Results: Twelve studies were included (seven randomized controlled trials and five non-randomized intervention studies). The most common intervention components were; needs assessments, dedicated care coordinators and multi-professional teams. Findings show that inter-organizational coordination could decrease- or even increase readmission rates, with similar findings for hospital length of stay and mortality. Furthermore, inter-organizational coordination seemed to have a positive impact on quality of life and activities of daily living.

Conclusion: Inter-organizational coordination could potentially reduce health-care utilization and improve quality of life for older patients with complex needs. However, the findings remain uncertain and further research is warranted.

Background This study assessed the cost-effectiveness of proton beam therapy (PBT) compared to conventional radiotherapy (CRT) for treating patients with brain tumors in Sweden.

Methods Data from a longitudinal non-randomized study performed between 2015 and 2020 was used, and included adult patients with brain tumors, followed during treatment and through a one-year follow-up. Clinical and demographic data were sourced from the longitudinal study and linked to Swedish national registers to get information on healthcare resource use. A cost-utility framework was used to evaluate the cost-effectiveness of PBT vs. CRT. Patients in PBT group (n = 310) were matched with patients in CRT group (n = 40) on relevant observables using propensity score matching with replacement. Costs were estimated from a healthcare perspective and included costs related to inpatient and specialized outpatient care, and prescribed medications. The health outcome was quality-adjusted life-years (QALYs), derived from the EORTC-QLQ-C30. Generalized linear models (GLM) and two-part models were used to estimate differences in costs and QALYs.

Results PBT yielded higher total costs, 14,639 US$, than CRT, 13,308 US$, with a difference of 1,372 US$ (95% CI, -4,914-7,659) over a 58 weeks' time horizon. Further, PBT resulted in non-significantly lower QALYs, 0.746 compared to CRT, 0.774, with a difference of -0.049 (95% CI, -0.195-0.097). The probability of PBT being cost-effective was < 30% at any willingness to pay.

Conclusions These results suggest that PBT cannot be considered a cost-effective treatment for brain tumours, compared to CRT. Trial registration Not applicable.

Mental health conditions are among the highest disease burden on society, affecting approximately 20% of children and adolescents at any point in time, with depression and anxiety being the leading causes of disability globally. To improve treatment outcomes, healthcare organizations turned to clinical decision support systems (CDSSs) that offer patient-specific diagnoses and recommendations. However, the economic impact of CDSS is limited, especially in child and adolescent mental health. This systematic literature review examined the economic impacts of CDSS implemented in mental health services. We planned to follow PRISMA reporting guidelines and found only one paper to describe health and economic outcomes. A randomized, controlled trial of 336 participants found that 60% of the intervention group and 32% of the control group achieved symptom reduction, i.e. a 50% decrease as per the Symptom Checklist-90-Revised (SCL-90-R), a method to evaluate psychological problems and identify symptoms. Analysis of the incremental cost-effectiveness ratio found that for every 1% of patients with a successful treatment result, it added <euro>57 per year. There are not enough studies to draw conclusions about the cost-effectiveness in a mental health context. More studies on economic evaluations of the viability of CDSS within mental healthcare have the potential to contribute to patients and the larger society.

Purpose

Our aim was to elicit a value set for Capability-Adjusted Life Years Sweden (CALY-SWE); a capability-grounded quality of life instrument intended for use in economic evaluations of social interventions with broad consequences beyond health.

Methods

Building on methods commonly used in the quality-adjusted life years EQ-5D context, we collected time-trade off (TTO) and discrete choice experiment (DCE) data through an online survey from a general population sample of 1697 Swedish participants. We assessed data quality using a score based on the severity of inconsistencies. For generating the value set, we compared different model features, including hybrid modeling of DCE and TTO versus TTO data only, censoring of TTO answers, varying intercept, and accommodating for heteroskedasticity. We also assessed the models’ DCE logit fidelity to measure agreement with potentially less-biased DCE data. To anchor the best capability state to 1 on the 0 to 1 scale, we included a multiplicative scaling factor.

Results

We excluded 20% of the TTO answers of participants with the largest inconsistencies to improve data quality. A hybrid model with an anchor scale and censoring was chosen to generate the value set; models with heteroskedasticity considerations or individually varying intercepts did not offer substantial improvement. The lowest capability weight was 0.114. Health, social relations, and finance and housing attributes contributed the largest capability gains, followed by occupation, security, and political and civil rights.

Conclusion

We elicited a value set for CALY-SWE for use in economic evaluations of interventions with broad social consequences.

A comprehensive review of the economic evidence on parenting interventions targeting different aspects of child health is lacking to support decision-making. The aim of this review is to provide an up to date synthesis of the available health economic evidence for parenting interventions aiming to improve child health. A systematic review was conducted with articles identified through Econlit, Medline, PsychINFO, and ERIC databases. Only full economic evaluations comparing two or more options, considering both costs and outcomes were included. We assessed the quality of the studies using the Drummond checklist. We identified 44 studies of varying quality that met inclusion criteria; 22 targeting externalizing behaviors, five targeting internalizing problems, and five targeting other mental health problems including autism and alcohol abuse. The remaining studies targeted child abuse (n = 5), obesity (n = 3), and general health (n = 4). Studies varied considerably and many suffered from methodological limitations, such as limited costing perspectives, challenges with outcome measurement and short-time horizons. Parenting interventions showed good value for money in particular for preventing child externalizing and internalizing behaviors. For the prevention of child abuse, some programs had the potential of being cost-saving over the longer-term. Interventions were not cost-effective for the treatment of autism and obesity. Future research should include a broader spectrum of societal costs and quality-of-life impacts on both children and their caregivers.

Importance: Behavior therapy is a recommended intervention for Tourette syndrome (TS) and chronic tic disorder (CTD), but availability is limited and long-term effects are uncertain.

Objective: To investigate the long-term efficacy and cost-effectiveness of therapist-supported, internet-delivered exposure and response prevention (ERP) vs psychoeducation for youths with TS or CTD.

Design, Setting, And Participants: This 12-month controlled follow-up of a parallel group, superiority randomized clinical trial was conducted at a research clinic in Stockholm, Sweden, with nationwide recruitment. In total, 221 participants aged 9 to 17 years with TS or CTD were enrolled between April 26, 2019, and April 9, 2021, of whom 208 (94%) provided 12-month follow-up data. Final follow-up data were collected on June 29, 2022. Outcome assessors were masked to treatment allocation throughout the study.

Interventions: A total of 111 participants were originally randomly allocated to 10 weeks of therapist-supported, internet-delivered ERP and 110 participants to therapist-supported, internet-delivered psychoeducation.

Main Outcomes And Measures: The primary outcome was within-group change in tic severity, measured by the Total Tic Severity Score of the Yale Global Tic Severity Scale (YGTSS-TTSS), from the 3-month follow-up to the 12-month follow-up. Treatment response was defined as 1 (very much improved) or 2 (much improved) on the Clinical Global Impression-Improvement scale. Analyses were intention-to-treat and followed the plan prespecified in the published study protocol. A health economic evaluation was performed from 3 perspectives: health care organization (including direct costs for treatment provided in the study), health care sector (additionally including health care resource use outside of the study), and societal (additionally including costs beyond health care [eg, parent's absenteeism from work]).

Results: In total, 221 participants were recruited (mean [SD] age, 12.1 [2.3] years; 152 [69%] male). According to the YGTSS-TTSS, there were no statistically significant changes in tic severity from the 3-month to the 12-month follow-up in either group (ERP coefficient, -0.52 [95% CI, -1.26 to 0.21]; P = .16; psychoeducation coefficient, 0.00 [95% CI, -0.78 to 0.78]; P > .99). A secondary analysis including all assessment points (baseline to 12-month follow-up) showed no statistically significant between-group difference in tic severity from baseline to the 12-month follow-up (coefficient, -0.38 [95% CI, -1.11 to 0.35]; P = .30). Treatment response rates were similar in both groups (55% in ERP and 50% in psychoeducation; odds ratio, 1.25 [95% CI, 0.73-2.16]; P = .42) at the 12-month follow-up. The health economic evaluation showed that, from a health care sector perspective, ERP produced more quality-adjusted life years (0.01 [95% CI, -0.01 to 0.03]) and lower costs (adjusted mean difference -$84.48 [95% CI, -$440.20 to $977.60]) than psychoeducation at the 12-month follow-up. From the health care organization and societal perspectives, ERP produced more quality-adjusted life years at higher costs, with 65% to 78% probability of ERP being cost-effective compared with psychoeducation when using a willingness-to-pay threshold of US $79 000.

Conclusions And Relevance: There were no statistically significant changes in tic severity from the 3-month through to the 12-month follow-up in either group. The ERP intervention was not superior to psychoeducation at any time point. While ERP was not superior to psychoeducation alone in reducing tic severity at the end of the follow-up period, ERP is recommended for clinical implementation due to its likely cost-effectiveness and support from previous literature.

The Russian invasion and annexation of eastern Ukraine and Crimea in 2014, along with the ongoing war since February, 2022, have inflicted incalculable damage to Ukraine with many deaths and injuries, massive population displacement, and extensive physical and emotional trauma. These events put an immense strain on the general health-care and mental health-care systems. For many years the mental health-care system in Ukraine was dominated by large psychiatric hospitals and residential institutions focusing on biological therapies; it was a system known for neglect, abuse, and human rights violations. While coping with current stressors, Ukraine is looking to the future with recovery initiatives and reforms to bring its health and social infrastructures to meet the needs of the Ukrainian people and international standards. This Lancet Psychiatry Commission was convened to identify the current mental health needs in Ukraine, and to outline a plan for a future, in which Ukrainians receive evidence-based care through a system that values human rights and lived experiences of people with mental illness. The Commission included five work- groups, each examining specific opportunities for change, development, and modernisation of the Ukrainian mental health-care system, along with requirements for success in clinical services, clinical training, research, forensics and legal advocacy, and finance. Workgroups built upon Ukraine's pre-war efforts to create a modern mental health-care system, while simultaneously looking at a 5-10-year horizon for bringing Ukrainian mental health care, training, research, and legal practices in line with international standards, which the country must meet in preparation for its expected European Union (EU) membership. 40 experts in mental health, health economics, law, science, and epidemiology, along with people with lived experience of mental illness, from 12 countries, joined to create this Commission.

Background: The aim of this study was to investigate the health and economic outcomes of a universal early intervention for parents and children, the Salut Programme, from birth to when the child completed five years of age.

Methods: This study adopted a retrospective observational design using routinely collected linked register data with respect to both exposures and outcomes from Vasterbotten county, in northern Sweden. Making use of a natural experiment, areas that received care-as-usual (non-Salut area) were compared to areas where the Programme was implemented after 2006 (Salut area) in terms of: (i) health outcomes, healthcare resource use and costs around pregnancy, delivery and birth, and (ii) healthcare resource use and related costs, as well as costs of care of sick child. We estimated total cumulative costs related to inpatient and specialised outpatient care for mothers and children, and financial benefits paid to mothers to stay home from work to care for a sick child. Two analyses were conducted: a matched difference-in difference analysis using the total sample and an analysis including a longitudinal subsample.

Results: The longitudinal analysis on mothers who gave birth in both pre- and post-measure periods showed that mothers exposed to the Programme had on average 6% (95% CI 3-9%) more full-term pregnancies and 2% (95% CI 0.03-3%) more babies with a birth weight >= 2500 g, compared to mothers who had care-as-usual. Savings were incurred in terms of outpatient care costs for children of mothers in the Salut area ($826). The difference-in-difference analysis using the total sample did not result in any significant differences in health outcomes or cumulative resource use over time.

Conclusions: The Salut Programme achieved health gains, as a health promotion early intervention for children and parents, in terms of more full-term pregnancies and more babies with a birth weight >= 2500 g, at reasonable cost, and may lead to lower usage of outpatient care. Other indicators point towards positive effects, but the small sample size may have led to underestimation of true differences.

Social-emotional problems occurring early in life can place children at future risk of adverse health, social and economic outcomes. Determinants of social-emotional problems are multi-layered and originate from different contexts surrounding children, though few studies consider them simultaneously. We adopted a holistic approach by using Bronfenbrenner's process-person-context-time model as a structuring device. We aimed to assess what characteristics of families and children from pregnancy, over birth, and up to 3 years of age are associated with social-emotional problems in boys and girls. This study used regional data from the Salut Programme, a universal health promotion programme implemented in Antenatal and Child Health Care, and data from national Swedish registers. The study population included 6033 3-year-olds and their parents during the period 2010-2018. Distinct logistic regression models for boys and girls were used to assess associations between the family social context, parents' lifestyle, parent's mental health, children's birth characteristics, and indicators of proximal processes (the independent variables); and children's social-emotional problems as measured by the parentcompleted Ages and Stages Questionnaire: Social-Emotional between 33 and 41 months of age (the outcome). Overall, a less favourable family social context, detrimental lifestyle of the parents during pregnancy, and parents' mental illness from pregnancy onwards were associated with higher odds of social-emotional problems in 3 -year-olds. Higher screentime and infrequent shared book-reading were associated with higher odds of socialemotional problems. The multifaceted determinants of children's social-emotional problems imply that many diverse targets for intervention exist. Additionally, this study suggests that Bronfenbrenner's process-person-context-time theoretical framework could be relevant for public health research and policy.