***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    ***EXAMPLES*** 
    Input: BACKGROUND Two-thirds of people with dementia live at home , receiving most care from family carers , about 40 % of whom have clinical ly significant depression or anxiety . This impacts on the person with dementia , families and society , predicting care breakdown . There are currently no clinical ly effective and cost-effective NHS family carer interventions . OBJECTIVES To assess the STrAtegies for RelaTives ( START ) intervention in the short ( 4 and 8 months ) and long term ( 1 and 2 years ) compared with treatment as usual ( TAU ) . DESIGN R and omised , parallel-group , superiority trial with blinded assessment recruiting participants 2:1 ( intervention to TAU ) to allow for therapist clustering . SETTING Three UK mental health services and one neurological service . PARTICIPANTS Family carers of people with dementia . INTERVENTION Eight-session manual-based coping intervention delivered by supervised psychology graduates to individuals . MAIN OUTCOME MEASURES Affective symptoms [ Hospital Anxiety and Depression Scale-total ( HADS-T ) ] and cost-effectiveness . Secondary measures : anxiety and depression symptoms and caseness , quality of life ( QoL ) , abusive behaviour and long-term care home admission . RESULTS Two hundred and sixty participants were r and omised ( 173 intervention , 87 TAU ) . We used intention-to-treat analysis in the short term ( 152 intervention , 77 TAU ) and in the long term ( 140 intervention , 69 TAU ) . In the short term , the intervention group had lower HADS-T [ mean difference -1.80 , 95 % confidence interval ( CI ) -3.29 to -0.31 ; p=0.02 ] and higher quality -adjusted life-years ( QALYs ) ( mean difference 0.03 , 95 % CI -0.01 to 0.08 ) . Costs were no different between groups [ mean £ 252 ( 95 % CI -£ 28 to £ 565 ) for intervention group ] . The cost-effectiveness acceptability curve showed a greater than 99 % chance of being cost-effectiveness at a £ 30,000/QALY willingness-to-pay threshold and a high probability of cost-effectiveness based on the HADS-T score . Carers in the intervention group had less case-level depression [ odds ratio ( OR ) 0.24 , 95 % CI 0.07 to 0.76 ] , a trend towards reduced case-level anxiety ( OR 0.30 , 95 % CI 0.08 to 1.05 ) , lower Hospital Anxiety and Depression Scale-anxiety ( HADS-A ) ( -0.91 , 95 % CI -1.76 to -0.07 ; p = 0.03 ) and Hospital Anxiety and Depression Scale-depression ( HADS-D ) ( -0.91 , 95 % CI -1.71 to -0.10 ; p = 0.03 ) and higher Health Status Question naire ( HSQ ) QoL ( mean difference 4.09 , 95 % CI 0.34 to 7.83 ) . Group differences in abusive behaviour ( OR 0.48 , 95 % CI 0.18 to 1.27 ) and the person with dementia 's quality of life-Alzheimer 's disease ( QoL-AD ) ( mean increase 0.59 , 95 % CI -0.72 to 1.89 ) were not significant . In the long term , the intervention group had lower HADS-T ( mean difference -2.58 , 95 % CI -4.26 to -0.90 ; p = 0.03 ) and higher QALYs ( mean difference 0.03 , 95 % CI -0.01 to 0.06 ) . Carers in the intervention group had less case-level depression ( OR 0.14 , 95 % CI 0.04 to 0.53 ) , a trend towards reduced case-level anxiety ( OR 0.57 , 95 % CI 0.26 to 1.24 ) , lower HADS-A ( -1.16 , 95 % CI -2.15 to -0.18 ) and HADS-D ( 1.45 , 95 % CI -2.32 to -0.57 ) , and higher HSQ ( mean difference 7.47 , 95 % CI 2.87 to 12.08 ) . Thirty-two ( 18.7 % ) people with dementia in the intervention group and 17 ( 20.2 % ) in TAU were admitted to a care home ( hazard ratio 0.83 , 95 % CI 0.44 to 1.56 ; p = 0.56 ) . There were no significant differences between groups in abusive behaviour ( OR 0.83 , 95 % CI 0.36 to 1.94 ) , the person with dementia 's QoL-AD ( 0.17 , 95 % CI -1.37 to 1.70 ) or costs ( £ 336 , 95 % CI -£ 223 to £ 895 ) for intervention group . The probability that the intervention would be seen as cost-effective at £ 30,000/QALY threshold and cost-effectiveness on the HADS-T remained high . CONCLUSIONS The START intervention was clinical ly effective and cost-effective in the short and longer term . The results are robust to the sensitivity analyses performed . Future work is needed to consider mechanism of action ; the effects on people with dementia in clinical terms ( cognition , neuropsychiatric symptoms , longer-term care home admission ) ; and on health and social care costs . In addition , we will explore the effects of carer abusive behaviour on the care recipient 's care home admission and if this then reduces abusive behaviour . We would also like to implement START and evaluate this implementation in clinical practice . TRIAL REGISTRATION Current Controlled Trials ISCTRN70017938 Background : Recommendations in the UK suggest restricting treatment of Alzheimer ’s disease with cholinesterase inhibitors , on cost-effectiveness grounds , to patients with moderate cognitive decline . As the economic analyses that informed these recommendations have been the subject of debate , we sought to address the potential limitations of existing models and produce estimates of donepezil treatment cost effectiveness in the UK using the most recent available data and simulation techniques . Methods : A discrete-event simulation was developed that predicts progression of Alzheimer ’s disease through correlated changes in cognition , behavioural disturbance and function . Patient-level data from seven r and omized , placebo-controlled donepezil trials and a 7-year follow-up registry provided the basis for modeling longitudinal outcomes . Individuals in the simulation were assigned unique demographic and clinical characteristics and then followed for 10 years , with severity of disease tracked on continuous scales . Patient mix and costs were developed from UK-specific literature . Analyses were run for severity subgroups to evaluate outcomes for sub- population s with disease of mild versus moderate severity from both a healthcare payer and societal perspective . All costs are reported in £ , year 2007 values , and all outcomes are discounted at 3.5 % per annum . Results : Over 10 years , treatment of all patients with mild to moderate disease  reduces overall direct medical costs by an average of over £ 2300 per patient . When unpaid caregiver time is also taken into consideration , savings increase to over £ 4700 per patient . Compared with untreated patients , patients receiving donepezil experience a discounted gain in QALYs averaging 0.11 , with their caregivers gaining , on average , 0.01 QALYs . For the subset of patients starting treatment with more severe disease , savings are more modest , averaging about £ 1600 and £ 3750 from healthcare and societal perspectives , respectively . In probabilistic sensitivity analyses , donepezil dominated no treatment between 57 % and 62 % of replications when only medical costs were considered , and between 74 % and 79 % of replications when indirect costs were included , with results more favourable for treatment initiation in the mild versus moderate severity stages of the disease . Conclusions : Although the simulation results are not definitive , they suggest that donepezil leads to health benefits and cost savings when used to treat mild to moderately severe Alzheimer ’s disease in the UK . They also indicate that both benefits and savings may be greatest when treatment is started while patients are still in the mild stages of Alzheimer ’s disease Objectives The objective of this article was to compare the costs and cost-effectiveness of the two most prominent types of case management in the Netherl and s ( intensive case management and linkage models ) against no access to case management ( control group ) for people with already diagnosed dementia and their informal caregivers . Methods The economic evaluation was conducted from a societal perspective embedded within a two year prospect i ve , observational , controlled , cohort study with 521 informal caregivers and community-dwelling persons with dementia .  Case management provided within one care organization ( intensive case management model , ICMM ) , case management where care was provided by different care organizations within one region ( Linkage model , LM ) , and a group with no access to case management ( control ) were compared . The economic evaluation related incremental costs to incremental effects regarding neuropsychiatric symptoms ( NPI ) , psychological health of the informal caregiver ( GHQ-12 ) , and quality adjusted life years ( QALY ) of the person with dementia and informal caregiver . Results Inverse-propensity-score-weighted models showed no significant differences in clinical or total cost outcomes between the three groups . Informal care costs were significantly lower in the ICMM group compared to both other groups . Day center costs were significantly lower in the ICMM group compared to the control group . For all outcomes , the probability that the ICMM was cost-effective in comparison with LM and the control group was larger than 0.97 at a threshold ratio of 0 € /incremental unit of effect . Conclusion This study provides preliminary evidence that the ICMM is cost-effective compared to the control group and the LM . However , the findings should be interpreted with caution since this study was not a r and omized controlled trial An economic evaluation was undertaken concurrently with a r and omized trial comparing a Caregiver Support Program ( CSP ) with existing conventional community nursing care for those caring for elderly relatives at home . The differences in re source consumption were compared with changes in caregiver quality of life , as measured by the Caregiver Quality of Life Instrument ( CQLI ) . A 20 % difference from baseline in the CQLI favored the experimental ( CSP ) group , although this did not reach conventional levels of statistical significance . A comparison of improvement in quality of life with costs implies an incremental cost per quality -adjusted life year gained of Canadian $ 20,000 for the CSP , which compares favorably with other health care interventions . Further , larger studies are required to confirm this result Objective To assess the cost utility of early psychosocial intervention for patients with Alzheimer 's disease and their primary caregivers . Design Cost utility evaluation alongside a multicentre , r and omised controlled trial with 3 years of follow-up . Setting Primary care and memory clinics in five Danish districts . Participants 330 community-dwelling patients and their primary caregivers . Intervention Psychosocial counselling and support lasting 8–12 months after diagnosis and follow-up at 3 , 6 , 12 and 36 months in the intervention group or follow-up only in the control group . Main outcome measures The primary outcome measure was the cost of additional quality -adjusted life years ( QALYs ) . Costs were measured from a societal perspective , including the costs of healthcare , social care , informal care and production loss . QALYs were estimated separately for the patient and the caregiver before aggregation for the main analysis . Results None of the observed cost and QALY measures were significantly different between the intervention and control groups , although a tendency was noted for psychosocial care leading to cost increases with informal care that was not outweighed by the tendency for cost savings with formal care . The probability of psychosocial intervention being cost-effective did not exceed 36 % for any threshold value . The alternative scenario analysis showed that the probability of cost-effectiveness increased over the range of threshold values used if the cost perspective was restricted to formal healthcare . Conclusions A multifaceted , psychosocial intervention programme was found unlikely to be cost-effective from a societal perspective . The recommendation for practice in setting s that are similar to the Danish setting is to provide follow-up with referral to available local support programmes when needed , and to restrict large multifaceted intervention programmes to patients and caregivers with special needs until further evidence for cost-effectiveness emerges . Trial registration The study was registered in the Clinical Trial Data base as IS RCT N74848736 Objective To assess whether the START ( STrAtegies for RelatTives ) intervention added to treatment as usual is cost effective compared with usual treatment alone . Design Cost effectiveness analysis nested within a pragmatic r and omised controlled trial . Setting Three mental health and one neurological outpatient dementia service in London and Essex , UK . Participants Family carers of people with dementia . Intervention Eight session , manual based , coping intervention delivered by supervised psychology graduates to  family carers of people with dementia added to usual treatment , compared with usual treatment alone . Primary outcome measures Costs measured from a health and social care perspective were analysed alongside the Hospital Anxiety and Depression Scale total score ( HADS-T ) of affective symptoms and quality adjusted life years ( QALYs ) in cost effectiveness analyses over eight months from baseline . Results Of the 260 participants recruited to the study , 173 were r and omised to the START intervention , and 87 to usual treatment alone .  Mean HADS-T scores were lower in the 
    Output:
    
Our critical review highlights the lack of cost – utility analyses of interventions to support informal carers .