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BACKGROUND: In individual studies and limited meta-analyses venlafaxine has been reported to be more effective than comparator antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs).
AIMS: To perform a systematic review of all such studies.
METHOD: We conducted a systematic review of double-blind, randomised trials comparing venlafaxine with alternative antidepressants in the treatment of depression. The primary outcome was the difference in final depression rating scale value, expressed as a standardised effect size. Secondary outcomes were response rate, remission rate and tolerability.
RESULTS: A total of 32 randomised trials were included. Venlafaxine was more effective than other antidepressants (standardised effect size was -0.14, 95% Cl -0.07 to -0.22). A similar significant advantage was found against SSRIs (20 studies) but not tricyclic antidepressants (7 studies).
CONCLUSIONS: Venlafaxine has greater efficacy than SSRIs although there is uncertainty in comparison with other antidepressants. Further studies are required to determine the clinical importance of this finding.
OBJECTIVES:The impact of economic evaluation studies on health-care decision makers has been shown to be rather limited. However, there is an increasing requirement for the cost-effectiveness of health-care interventions to be considered in formulating and implementing guidelines for clinical practice. This paper reports the findings of recent focus group research among UK health authorities, which examined the usefulness of published economic evaluations within the decision-making processes. The findings are presented and discussed in light of other studies that have addressed this issue.
METHODS: Focus group research was conducted with decision makers from a sample of two UK health authorities using the National Health Service Economic Evaluation Database (NHS EED) as a research vehicle to locate and report the findings of relevant economic studies. The study sample was initially invited to respond to questionnaires exploring the usefulness of published economic evaluations in the decision-making process and to outline particular topics that it felt would benefit from similar economic evidence. Following this, a detailed search was undertaken to retrieve structured NHS EED abstracts on these topics such that the usefulness and limitations of economic evaluations to decision making could be determined.
RESULTS: Decision makers generally recognized the usefulness and necessity of published economic evaluations in informing their decision-making processes. However, the value of studies was often limited because of the poor generalizability of results, the narrowness of research questions, and the lack of methodological rigor common to many published studies. A total of 237 NHS EED full abstracts were retrieved in the specified areas of interest, which, within specified caveats, were generally found to be useful as decision-making tools. There was a general consensus among decision makers in favor of developing a quality-scoring system for studies, thereby going beyond the critical summaries given in NHS EED.
CONCLUSIONS: Decision makers value information on cost-effectiveness as well as effectiveness alone, but methodological improvements are necessary to increase the reliability of economic studies. A quality-scoring system for published studies would be a useful development as a filtering mechanism for decision makers but would raise a number of challenges for health economists.
No abstract available
This study illustrates a process of accessing and utilising clinical and economic evidence in health care decision making. The scenario examined was that of a UK Health Authority evaluating evidence prior to the introduction of assertive community treatment (ACT), as part of guidance from the UK National Service Framework for Mental Health. The consistency between clinical and cost evidence from a number of sources (Cochrane Database of Systematic Reviews (CDSR), Database of Reviews of Effectiveness (DARE), HTA database, NHS Economic Evaluation database (NHS EED)) was also addressed, as was the usefulness of structured abstracts on NHS EED. The findings showed that within specified caveats ACT tends to be more effective and also less costly than alternative interventions; there is general agreement between sources principally reporting effectiveness and economic evaluations; and NHS EED abstracts are useful in the decision making process where information gaps exist. In terms of health care policy in the health authority examined, two ACT teams were subsequently introduced in the city of Leicester. Although systematic reviews and appraisals of evidence are arguably the gold standard in health care decision making, the study illustrates how the use of databases of structured abstracts can assist in making optimal choices in real life decision making scenarios.
Debates about euthanasia have tended to exclude any economic arguments. This might be due to the narrow perspective of the economic arguments presented to date, most of which focus on the health care costs in the last year of life. This paper considers the wider economic aspects in decisions to end life, including potential methodological weaknesses in measuring costs in the last year of life, the costs of euthanasia itself, the value of patient preferences and the value (and problems) of choice. Suggestions are made on how these economic issues might be explored to take the economic arguments forward.
No abstract available
Search filters are increasingly used to search medical databases to identify specific topics or study designs. In particular, search filters have been designed to help health-care professionals identify systematic reviews of the effectiveness of health interventions. Identifying systematic reviews in databases such as MEDLINE is problematic and research has previously been undertaken into methods to design search filters that retrieve systematic reviews effectively. The aim of this study was to improve previously developed methods to derive a more objective search strategy to identify systematic reviews in MEDLINE. A 'quasi-gold standard' collection of known systematic reviews was identified. A frequency analysis of words within a subset of the 'quasi-gold standard' was undertaken followed by a statistical analysis of the most frequently occurring words. This analysis determined which terms would best distinguish between systematic reviews, non-systematic reviews and non-reviews. The performance of the best models was tested on the remaining subset of 'quasi-gold standard' records and then using the OVID interface to MEDLINE. The best model had a sensitivity of 73.4% for systematic reviews in the test set and 84.2% when used with the validation set. The best model had a specificity of 98.3% in the test set and 93% in the validation set. When tested on the same 'quasi-gold standard' using OVID MED-LINE the model showed 100% sensitivity and 4.4% precision. The number of times a term occurs in a record adds discriminatory power to the search strategy. Apparently highly relevant terms chosen subjectively do not perform as well as those derived by a statistical approach. Some search terms may not immediately seem useful in identifying systematic reviews, but when used in combination with other terms they prove to be highly discriminating. The best performing filters were tested on the OVID interface, but without frequency and term weightings. Their performance was also compared to previously published filters. One of the strategies was found to perform better with respect to sensitivity than previously published filters, although with lower precision.
