A systematic review of health technology assessment tools in sub-Saharan Africa: methodological issues and implications

BACKGROUND

Health technology assessment (HTA) is mostly used in the context of high- and middle-income countries. Many "resource-poor" settings, which have the greatest need for critical assessment of health technology, have a limited basis for making evidence-based choices. This can lead to inappropriate use of technologies, a problem that could be addressed by HTA that enables the efficient use of resources, which is especially crucial in such settings. There is a lack of clarity about which HTA tools should be used in these settings. This research aims to provide an overview of proposed HTA tools for "resource-poor" settings with a specific focus on sub-Saharan Africa (SSA).

METHODOLOGY

A systematic review was conducted using basic steps from the PRISMA guidelines. Studies that described HTA tools applicable for "resource-limited" settings were identified and critically appraised. Only papers published between 2003 and 2013 were included. The identified tools were assessed according to a checklist with methodological criteria.

RESULTS

Six appropriate tools that are applicable in the SSA setting and cover methodological robustness and ease of use were included in the review. Several tools fulfil these criteria, such as the KNOW ESSENTIALS tool, Mini-HTA tool, and Multi-Criteria Decision Analysis but their application in the SSA context remains limited. The WHO CHOICE method is a standardized decision making tool for choosing interventions but is limited to their cost-effectiveness. Most evaluation of health technology in SSA focuses on priority setting. There is a lack of HTA tools that can be used for the systematic assessment of technology in the SSA context.

CONCLUSIONS

An appropriate HTA tool for "resource-constrained" settings, and especially SSA, should address all important criteria of decision making. By combining the two most promising tools, KNOW ESSENTIALS and Multi-Criteria Decision Analysis, appropriate analysis of evidence with a robust and flexible methodology could be applied for the SSA setting.

Clinical assessment of amyloid imaging in Alzheimer's disease: a systematic review of the literature

BACKGROUND/AIMS

Healthcare systems face an increased prevalence of Alzheimer's disease and increasing costs. The use of molecular biomarkers and imaging could offer an effective solution for these issues. The objective of this study was to assess amyloid imaging regarding clinical utility and impact.

METHODS

A literature search was performed in several databases, searching articles between 2008 and January 2013 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The results are reported according to the clinical correlates of amyloid imaging.

RESULTS

Thirty-three studies were included in the final analysis. Five studies evaluated amyloid imaging for diagnosis. Nine studies assessed the prognostic value. Twenty-two studies provided correlations to cognitive measures. Amyloid imaging provides a high reliability in diagnosis and prognosis, but cognitive measures only showed weak correlations.

CONCLUSION

The evidence clearly indicated that amyloid imaging has not arrived yet in clinical practice. However, it can provide substantial benefits in special aspects of diagnostic accuracy and for a diagnosis up to 10 years before clinical diagnosis. This can be a base for early preventive treatment strategies such as anti-amyloid therapy. In this context, amyloid imaging is crucial to understand the early pathologic process in Alzheimer's disease.

Incidence and predictors of post-stroke epilepsy

BACKGROUND AND AIMS

Stroke is the leading cause of seizures and epilepsy in the elderly. The aim of this study was to assess the incidence of post-stroke epilepsy (PSE) based on the revised epilepsy definition of the International League Against Epilepsy (ILAE) in a population-based study and to describe possible predictors.

METHODS

Data from the prospective population-based Erlangen Stroke Project (ESPro) were collected to describe the frequency of PSE. Patients were followed up 3, 12, and 24 months after stroke. Stroke was diagnosed according to the WHO and PSE according to the new ILAE criteria. Multivariable analysis was performed to identify predictors of PSE including age, sex, stroke type, stroke severity, and comorbidities.

RESULTS

From 1998 to 2006, 1815 patients with first-ever stroke were included (55.7% women; mean age 72.7 years, SD 13). Patients with known (n = 52) or unknown (n = 331) prior-to-stroke epilepsy or no available information on post-stroke seizures (n = 412) were excluded. From the remaining 1020 patients, 84 (8.2%) developed PSE within 2 years after stroke. Univariate analysis demonstrated stroke severity (P < 0.001) and hypertension (P < 0.05) as predictors for PSE. In multivariable analysis, stroke severity remained the only independent predictor (P = 0.002).

CONCLUSIONS

Based on the revised ILAE definition of epilepsy, the incidence of PSE was high in the ESPro. The only independent predictor for PSE was stroke severity.

Personalized medicine in screening for malignant disease: a review of methods and applications

Personalized medicine (PM) is currently a hot topic in the professional world. It is often called the medicine of the future and has already achieved resounding success in the area of targeted therapy. Nevertheless, integration of the concepts of PM into routine clinical practice is slow. This review is intended to give an overview of current and potential applications of PM in oncology. PM could soon play a decisive role, especially in screening. The relevance of PM in screening was examined in the case of four common cancers (colorectal cancer, lung cancer, breast cancer, and prostate cancer). A literature search was performed. This showed that biomarkers in particular play a crucial role in screening. In summary, it can be emphasized that there are already numerous known promising biomarkers in malignant disease. This results in several possibilities for individualizing and revolutionizing screening.

Changes in cognitive function over 3 years after first-ever stroke and predictors of cognitive impairment and long-term cognitive stability: the Erlangen Stroke Project

BACKGROUND AND PURPOSE

Cognitive impairment (CI) is frequent after stroke, but data from population-based stroke cohorts on the natural course of CI are limited. The purpose of this study was to determine changes in cognitive status over 3 years after stroke.

METHODS

Data were collected from the Erlangen Stroke Project, an ongoing population-based stroke registry. The Mini-Mental State Examination (MMSE) for assessing global cognitive function was used; CI was defined as an MMSE score <24.

RESULTS

From February 1998 to January 2006, 630 patients with first-ever stroke were included. Prevalence rates of CI at 3 months, 1 and 3 years were 15, 13, and 12%. In multivariable analysis, stroke severity, i.e. Barthel index (p < 0.001), age (OR = 1.03; 95% CI = 1.00-1.05) and diabetes mellitus (OR = 2.03; 95% CI = 1.13-3.67) were associated with CI at 3 months. Recovery rate from CI at 3 months after stroke was found to be 31% over the following 3 years. Intact cognitive function rate was 71% over 3 years and inversely associated with age (OR = 0.96; 95% CI = 0.96-0.94) and stroke severity (p < 0.001).

CONCLUSION

CI is frequent among stroke survivors and associated with age, stroke severity, and diabetes mellitus, but recovery occurs in approximately one third of the patients over the course of 3 years. Factors affecting intact cognitive function over time are increasing age and stroke severity.

Risk and cumulative risk of stroke recurrence: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Estimates of risk of stroke recurrence are widely variable and focused on the short- term. A systematic review and meta-analysis was conducted to estimate the pooled cumulative risk of stroke recurrence.

METHODS

Studies reporting cumulative risk of recurrence after first-ever stroke were identified using electronic databases and by manually searching relevant journals and conference abstracts. Overall cumulative risks of stroke recurrence at 30 days and 1, 5, and 10 years after first stroke were calculated, and analyses for heterogeneity were conducted. A Weibull model was fitted to the risk of stroke recurrence of the individual studies and pooled estimates were calculated with 95% CI.

RESULTS

Sixteen studies were identified, of which 13 studies reported cumulative risk of stroke recurrence in 9115 survivors. The pooled cumulative risk was 3.1% (95% CI, 1.7-4.4) at 30 days, 11.1% (95% CI, 9.0-13.3) at 1 year, 26.4% (95% CI, 20.1-32.8) at 5 years, and 39.2% (95% CI, 27.2-51.2) at 10 years after initial stroke. Substantial heterogeneity was found at all time points. This study also demonstrates a temporal reduction in 5-year risk of stroke recurrence from 32% to 16.2% across the studies.

CONCLUSIONS

The cumulative risk of recurrence varies greatly up to 10 years. This may be explained by differences in case mix and changes in secondary prevention over time However, methodological differences are likely to play an important role and consensus on definitions would improve future comparability of estimates and characterization of groups of stroke survivors at increased risk of recurrence.

Development and Implementation of Evidence-Based Indicators for Measuring Quality of Acute Stroke Care

Background and Purpose— There is no consensus about indicators for measuring quality of acute stroke care in Germany. Therefore, a standardized process was initiated recently to develop and implement evidence-based indicators for the measurement of quality of acute hospital stroke care.

Methods— Quality indicators were developed by a multidisciplinary board between November 2003 and December 2005. The process was initiated by the German Stroke Registers Study Group in cooperation with the German Stroke Society, the German Society of Neurology, the German Stroke Foundation, Regional Offices for Quality Assurance and other experts proven in the field. National and international recommendations were considered during the development process. The process was based on a systematic literature review, an independent external evaluation of the process and its results, and a prospective pilot study to evaluate the defined indicators in clinical practice.

Results— Overall a set of 24 indicators was developed to measure performance of acute care hospitals in the 3 health care dimensions structure, process and outcome as well as in 3 treatment phases prehospital, in-hospital/acute and postacute. Practicability of the derived indicators was tested in a prospective pilot study. During a 2-month period, 1006 patients in 13 hospitals were documented. Application of the new indicator set was found to be feasible by participating physicians and hospitals. Median time to document the required information for 1 patient was 5 minutes. Nationwide implementation of the new indicator set within regional registers in Germany started since April 2006.

Conclusions— The development of indicators to measure hospital performance in stroke care is an important step toward improving stroke care on a national level. The chosen standardized evidence-based approach ensures maximal transparency, acceptance and sustainability of the developed indicators in Germany.

Lifetime Cost of Ischemic Stroke in Germany: Results and National Projections From a Population-Based Stroke Registry

Background and Purpose— The number of stroke patients and the healthcare costs of strokes are expected to rise. The objective of this study was to determine the direct costs of first ischemic stroke and to estimate the expected increase in costs in Germany.

Methods— An incidence-based, bottom-up, direct-cost-of-ischemic-stroke study from the third-party payer’s perspective was performed, incorporating 10-year survival data and 5-year resource use data from the Erlangen Stroke Registry. Discounted lifetime year 2004 costs per case were obtained and applied to the expected age and sex evolution of the German resident population in the period 2006 to 2025.

Results— The overall cost per first-year survivor of first-ever ischemic stroke was estimated to be 18 517 euros (EUR). Rehabilitation accounted for 37% of this cost, whereas in subsequent years outpatient care was the major cost driver. Discounted lifetime cost per case was 43 129 EUR overall and was higher in men (45 549 EUR) than in women (41 304 EUR). National projections for the period 2006 to 2025 showed 1.5 million and 1.9 million new cases of ischemic stroke in men and women, respectively, at a present value of 51.5 and 57.1 billion EUR, respectively.

Conclusions— The number of stroke patients and the healthcare costs of strokes in Germany will rise continuously until the year 2025. Therefore, stroke prevention and reduction of stroke-related disability should be made priorities in health planning policies.

Care needs and economic consequences after acute ischemic stroke: the Erlangen Stroke Project

The objective was to determine the functional outcome, location of care and economic consequences in the first 3 months after ischemic stroke. As part of the Erlangen Stroke Project, (ESPro) information was collected on patients suffering a first-ever ischemic stroke. Three months after the stroke, location of care, dependence on caregivers and function based on Barthel Index: poor (0-55), moderate (60-90) or good function (95-100) were recorded. Data about health services used were combined with cost estimates for Germany (2000 Euros, undiscounted). Of 491 patients hospitalized, 383 were alive 3 months afterwards, 79% residing in the community. The majority of patients with poor function (60%) were still in institutional care. Patients with good function typically accrued the lowest costs, whether in an institution (17 965) or not (11 032) compared with poorer function who were living in an institution (poor: 26 370; moderate: 28,121), or community (poor: 27,207; moderate: 19,350). Hospitalization and rehabilitation services were the major costs accrued at each level of function. Many patients were left requiring a substantial amount of care and the costs associated with providing institutional care has a major impact on the economic consequences of a stroke.

Untersuchung der Reliabilität der deutschen Version des Barthel-Index sowie Entwicklung einer postalischen und telefonischen Fassung für den Einsatz bei Schlaganfall-Patienten

BACKGROUND AND PURPOSES

Aim of the study was to translate the original version of the Barthel-Index (BI) into German and to investigate the reliability of the German version. In addition, a German version of the BI for postal and telephone use was developed.

METHODS

Data were collected in four neurological hospitals in Germany. The translation of the BI followed the protocol of the Medical Outcomes Trust. The interrater reliability of the German version of the BI was investigated in 72 patients after acute stroke. The reliability of the postal and telephone version of the BI was compared with face-to-face interview in 147 patients three months after stroke. Reliability was assessed using simple weighted kappa-statistics.

RESULTS

The interrater reliability of the German version of the BI was excellent (mean kappa 0.93). The mean kappa coefficient was 0.79 for the postal version of the BI and 0.80 for the telephone version. Thus, the agreement between the postal and the telephone administration of the BI compared to the face-to-face interview was substantial to excellent.

CONCLUSIONS

Our study published the first German version of the BI which was investigated for interrater reliability in a standardized way. The development of a postal and a telephone version allows the widespread use of the German BI for the follow up of stroke patients in different access paths.

Predictors of in-hospital mortality in patients with acute ischemic stroke treated with thrombolytic therapy

CONTEXT

Data are limited regarding the risks and benefits of thrombolytic therapy for acute ischemic stroke outside of clinical trials.

OBJECTIVE

To investigate predictors of in-hospital mortality in patients with ischemic stroke treated with intravenous tissue plasminogen activator (tPA) within a pooled analysis of large German stroke registers.

DESIGN AND SETTING

Prospective, observational cohort study conducted at 225 community and academic hospitals throughout Germany cooperating within the German Stroke Registers Study Group.

PATIENTS

A total of 1658 patients with acute ischemic stroke who were admitted to study hospitals between 2000 and 2002 and were treated with tPA.

MAIN OUTCOME MEASURE

In-hospital mortality.

RESULTS

One hundred sixty-six patients (10%) who received tPA died during hospitalization, with 67.5% of these deaths occurring within 7 days. Factors predicting in-hospital death after tPA use were older age (for each 10-year increment in age, adjusted odds ratio [OR], 1.6; 95% confidence interval [CI], 1.3-1.9) and altered level of consciousness (adjusted OR, 3.4; 95% CI, 2.4-4.7). The overall rate of symptomatic intracranial hemorrhage was 7.1% and increased with age. One or more serious complications was observed in 27.2% of all patients and in 83.9% of patients who died after tPA treatment. An inverse relation between the number of patients treated with tPA in the respective hospital and the risk of in-hospital death was observed (adjusted OR, 0.97; 95% CI, 0.96-0.99 for each additional patient treated with tPA per year).

CONCLUSION

In patients with ischemic stroke who are treated with tPA, disturbances of consciousness and increasing age are associated with increased in-hospital mortality.

Predictors of In-Hospital Mortality and Attributable Risks of Death After Ischemic StrokeThe German Stroke Registers Study Group

BACKGROUND

There is a lack of information about factors associated with in-hospital death and the impact of neurological complications on early outcome for patients with stroke treated in community settings. We investigated predictors for in-hospital mortality and attributable risks of death after ischemic stroke in a pooled analysis of large German stroke registers.

METHODS

Stroke patients admitted to hospitals cooperating within the German Stroke Registers Study Group (ADSR) between January 1, 2000, and December 31, 2000, were analyzed. The ADSR is a network of regional stroke registers, combining data from 104 academic and community hospitals throughout Germany. The impact of patients' demographic and clinical characteristics, their comorbid conditions, and the treating hospital expertise in stroke care on in-hospital mortality was analyzed using Cox regression analysis. Attributable risks of death for medical and neurological complications were calculated.

RESULTS

A total of 13 440 ischemic stroke patients were included. Overall in-hospital mortality was 4.9%. In women, higher age (P<.001), severity of stroke defined by number of neurological deficits (P<.001), and atrial fibrillation (hazard ratio [HR], 1.3; 95% confidence interval [CI], 1.0-1.6) were independent predictors for in-hospital death. In men, diabetes (HR, 1.3; 95% CI, 1.0-1.8) and previous stroke (HR 1.4; 95% CI, 1.0-1.9) had a significant negative impact on early outcome in addition to the factors identified for women. The complication with the highest attributable risk proportion was increased intracranial pressure, accounting for 94% (95% CI, 93.9%-94.1%) of deaths among patients with this complication. Pneumonia was the complication with the highest attributable proportion of death in the entire stroke population, accounting for 31.2% (95% CI, 30.9%-31.5%) of all deaths. More than 50% of all in-hospital deaths were caused by serious medical or neurological complications (54.4%; 95% CI, 54.3%-54.5%).

CONCLUSIONS

Substantial differences were found in the impact of comorbid conditions on early outcome for men and women. Programs aiming at an improvement in short-term outcome after stroke should focus especially on a reduction of pneumonia and an early treatment of increased intracranial pressure.

Telemedizinisch vernetzte Schlaganfallstationen

More than 100 stroke units have been established in Germany. In rural areas, however, acute stroke care needs to be improved. In order to advance clinical stroke therapy, two specialized stroke centers founded a telemedicine network (TEMPiS) among 12 community hospitals in eastern Bavaria. Each network hospital established specialized stroke wards where qualified teams manage acute stroke patients. Twenty-four hours daily, physicians in local hospitals are able to contact the stroke centers via videoconferencing including transmission of digital DICOM data. To study the efficacy of this network, a controlled trial will be performed. Five TEMPiS-network hospitals will be matched with five other hospitals equal in size, catchment area, and diagnostic techniques. For about 1 year, all consecutive stroke cases in the matched study hospitals will be prospectively recorded in a database. Neurological deficits will be quantified on the National Institute of Health Stroke Scale within 24 h after stroke onset. Mortality and institutional care as a combined primary endpoint will be assessed after 3 and 12 months. Furthermore, functional outcome according to the modified Rankin scale, Barthel score, and quality of life will be assessed using a standard telephone interview. Data acquisition started in July 2003, and final results are expected in 2005.

Einflussfaktoren auf die stationäre Liegezeit nach Schlaganfall in Deutschland

BACKGROUND

In Germany up-to-date data within community settings about factors influencing length of stay in acute hospitals are lacking. We, therefore, identified predictors for length of stay in acute hospital after ischemic stroke in a pooled analysis of large German stroke registers.

METHODS

Ischemic stroke patients admitted to hospitals cooperating within the German Stroke Registers Study Group (ADSR) between January 1, 2000 and December 31, 2000 were analysed. The influence of patients' demographic and clinical characteristics as well as the characteristics of the treating hospitals on length of stay were analysed by multivariate linear regression.

RESULTS

Overall, 13 440 patients after ischemic stroke were included in the analyses. Their mean age was 70 years, 53 % were men. Median length of stay in acute hospitals was 12 days. In multivariate analyses younger age, an increasing number of co-morbidities, and an increasing number of neurological deficits were identified as predictors of prolonged stay in hospital. Patients were more likely to stay longer in an acute hospital if they were to be discharged to a rehabilitation unit or to a nursing home. Length of stay was independently decreased for patients treated in hospitals providing acute stroke unit services and for hospitals treating more than 250 stroke patients per year.

CONCLUSION

In addition to patients' demographic and clinical characteristics, length of stay in hospital was influenced by the hospitals' characteristics. Especially the volume of treated patients and the organisation of services within the hospital may play the key role.