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Oquendo B, Nouhaud C, Jarzebowski W, Leger A, Oasi C, Ba M, Lafuente-Lafuente C, Belmin J. Better functional recovery after acute stroke in older patients managed in a new dedicated post-stroke geriatric unit compared to usual management. J Nutr Health Aging 2024; 28:100033. [PMID: 38341964 DOI: 10.1016/j.jnha.2023.100033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 12/08/2023] [Indexed: 02/13/2024]
Abstract
OBJECTIVES A Stroke care Pathway dedicated to the ELders (SPEL) for patients with acute stroke was created in 2013 at the hospitals Pitié-Salpêtrière-Charles Foix (Paris, France). It is characterized by a stroke unit dedicated to emergency stroke care, and a post stroke geriatric unit (PSGU) including rehabilitation and management of geriatric syndromes. The aim of the study was to compare the functional recovery of patients transferred to PSGU versus other rehabilitation care in patients over 70 years of age after stroke. DESIGN A cohort observational study over a 4-year period. SETTING Hospitals Pitié-Salpêtrière and Charles Foix (Paris, France). PARTICIPANTS We studied patients over 70 years admitted to the participating stroke unit for acute stroke consecutively hospitalized from January 1, 2013, to January 1, 2017. INTERVENTION Patients transferred in the PSGU were compared to those admitted in other rehabilitation units. MEASUREMENTS The primary outcome was 3-month functional recovery after stroke. The secondary outcomes were the hospital length of stay and the returning home rate. A multivariable logistic regression was applied to adjust for confounding variables (age, sex, NIHSS score and Charlson's comorbidity score). RESULTS Among the 262 patients included in the study, those in the PGSU were significantly older, had a higher Charlson's comorbidity score and a higher initial NIHSS severity score. As compared to the other patients, functional recovery at 3 months was better in the PSGU (Rankin's score decreased by 0.80 points versus 0.41 points, p = 0.01). The average total length of stay was reduced by 16 days in the patients referred to the PSGU (p = 0.002). There was no significant difference in the returning home rate between the two groups (p = 0.88). CONCLUSION The SPEL which includes a post-stroke geriatric unit (PSGU) has been associated with improved recovery and had a positive impact in the management of older post-stroke patients.
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Affiliation(s)
- Bruno Oquendo
- Service de Gériatrie à orientation Cardiologique et Neurologique, APHP, Hôpitaux universitaires Pitié-Salpêtrière-Charles Foix, Ivry-sur-Seine, France; Sorbonne Université, Paris, France.
| | | | | | - Anne Leger
- Urgences Cérébro-Vasculaires, APHP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Christel Oasi
- Service de Gériatrie à orientation Cardiologique et Neurologique, APHP, Hôpitaux universitaires Pitié-Salpêtrière-Charles Foix, Ivry-sur-Seine, France
| | - Massamba Ba
- Service de Gériatrie à orientation Cardiologique et Neurologique, APHP, Hôpitaux universitaires Pitié-Salpêtrière-Charles Foix, Ivry-sur-Seine, France
| | - Carmelo Lafuente-Lafuente
- Service de Gériatrie à orientation Cardiologique et Neurologique, APHP, Hôpitaux universitaires Pitié-Salpêtrière-Charles Foix, Ivry-sur-Seine, France; Sorbonne Université, Paris, France
| | - Joel Belmin
- Service de Gériatrie à orientation Cardiologique et Neurologique, APHP, Hôpitaux universitaires Pitié-Salpêtrière-Charles Foix, Ivry-sur-Seine, France; Sorbonne Université, Paris, France
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Darvishi A, Mousavi M, Abdi Dezfouli R, Shirazikhah M, Alizadeh Zarei M, Hendi H, Joghataei F, Daroudi R. Cost-benefit analysis of stroke rehabilitation in Iran. Expert Rev Pharmacoecon Outcomes Res 2023:1-11. [PMID: 37024292 DOI: 10.1080/14737167.2023.2200938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
BACKGROUND The economic evaluation of medication interventions for stroke has been the subject of much economic research. This study aimed to examine the cost-benefit of multidisciplinary rehabilitation services for stroke survivors in Iran. METHODS This economic evaluation was conducted from the payer's perspective with a lifetime horizon in Iran. A Markov model was designed and Quality-adjusted life years (QALYs) were the final outcomes. First, to evaluate the cost-effectiveness, the incremental cost-effectiveness ratio (ICER) was calculated. Then, using the average net monetary benefit (NMB) of rehabilitation, the average Incremental Net Monetary Benefit (INMB) per patient was calculated. The analyses were carried out separately for public and private sector tariffs. RESULTS While considering public tariffs, the rehabilitation strategy had lower costs (US$5320 vs. US$ 6047) and higher QALYs (2.78 vs. 2.61) compared to non-rehabilitation. Regarding the private tariffs, the rehabilitation strategy had slightly higher costs (US$6,698 vs. US$6,182) but higher QALYs (2.78 vs. 2.61) compared to no rehabilitation. The average INMB of rehabilitation vs non-rehabilitation for each patient was estimated at US$1518 and US$275 based on Public and private tariffs, respectively. CONCLUSION Providing multidisciplinary rehabilitation services to stroke patients was cost-effective and has positive INMBs in public and private tariffs.
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Affiliation(s)
- Ali Darvishi
- Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mirtaher Mousavi
- Social Welfare Management Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Ramin Abdi Dezfouli
- Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Marzieh Shirazikhah
- Social Determinants of Health (By Research), Social Determinants of Health Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Mehdi Alizadeh Zarei
- Department of Occupational Therapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Hendi
- Department of Social Welfare Management, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Faezeh Joghataei
- Department of Social Welfare Management, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Rajabali Daroudi
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
- National Center for Health Insurance Research, Tehran, Iran
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Curioni C, Silva AC, Damião J, Castro A, Huang M, Barroso T, Araujo D, Guerra R. The Cost-Effectiveness of Homecare Services for Adults and Older Adults: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3373. [PMID: 36834068 PMCID: PMC9960182 DOI: 10.3390/ijerph20043373] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/01/2023] [Accepted: 02/01/2023] [Indexed: 06/18/2023]
Abstract
This study provides an overview of the literature on the cost-effectiveness of homecare services compared to in-hospital care for adults and older adults. A systematic review was performed using Medline, Embase, Scopus, Web of Science, CINAHL and CENTRAL databases from inception to April 2022. The inclusion criteria were as follows: (i) (older) adults; (ii) homecare as an intervention; (iii) hospital care as a comparison; (iv) a full economic evaluation examining both costs and consequences; and (v) economic evaluations arising from randomized controlled trials (RCTs). Two independent reviewers selected the studies, extracted data and assessed study quality. Of the 14 studies identified, homecare, when compared to hospital care, was cost-saving in seven studies, cost-effective in two and more effective in one. The evidence suggests that homecare interventions are likely to be cost-saving and as effective as hospital. However, the included studies differ regarding the methods used, the types of costs and the patient populations of interest. In addition, methodological limitations were identified in some studies. Definitive conclusions are limited and highlight the need for better standardization of economic evaluations in this area. Further economic evaluations arising from well-designed RCTs would allow healthcare decision-makers to feel more confident in considering homecare interventions.
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Affiliation(s)
- Cintia Curioni
- Institute of Nutrition, State University of Rio de Janeiro, R. São Francisco Xavier, 524-12º Andar-Bloco E-Sala 12008-Maracanã, Rio de Janeiro 20550-170, Brazil
| | - Ana Carolina Silva
- Institute of Nutrition, State University of Rio de Janeiro, R. São Francisco Xavier, 524-12º Andar-Bloco E-Sala 12008-Maracanã, Rio de Janeiro 20550-170, Brazil
| | - Jorginete Damião
- Institute of Nutrition, State University of Rio de Janeiro, R. São Francisco Xavier, 524-12º Andar-Bloco E-Sala 12008-Maracanã, Rio de Janeiro 20550-170, Brazil
| | - Andrea Castro
- Department of Family Medicine, State University of Rio de Janeiro, Boulevard 28 de Setembro, 77-Vila Isabel, Rio de Janeiro 20551-030, Brazil
| | - Miguel Huang
- Institute of Nutrition, State University of Rio de Janeiro, R. São Francisco Xavier, 524-12º Andar-Bloco E-Sala 12008-Maracanã, Rio de Janeiro 20550-170, Brazil
| | - Taianah Barroso
- Hospital Estadual Ary Parreiras, R. Dr. Luiz Palmier, 762-Barreto, Niterói 24110-310, Brazil
| | - Daniel Araujo
- Institute of Nutrition, State University of Rio de Janeiro, R. São Francisco Xavier, 524-12º Andar-Bloco E-Sala 12008-Maracanã, Rio de Janeiro 20550-170, Brazil
| | - Renata Guerra
- Health Technology Assessment Unit, Brazilian National Institute of Cancer, R. Marques de Pombal, 125-7º andar-Centro, Rio de Janeiro 20230-240, Brazil
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Zhang H, Yin G. Response‐adaptive rerandomization. J R Stat Soc Ser C Appl Stat 2021. [DOI: 10.1111/rssc.12513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Hengtao Zhang
- Department of Statistics and Actuarial Science The University of Hong Kong Pokfulam RoadHong Kong
| | - Guosheng Yin
- Department of Statistics and Actuarial Science The University of Hong Kong Pokfulam RoadHong Kong
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Taft K, Laing B, Wensley C, Nielsen L, Slark J. Health promotion interventions post-stroke for improving self-management: A systematic review. JRSM Cardiovasc Dis 2021; 10:20480040211004416. [PMID: 33996032 PMCID: PMC8082985 DOI: 10.1177/20480040211004416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 11/16/2022] Open
Abstract
Background It is well-documented that women tend to be worse off post-stroke. They are often frailer, have less independence, lower functionality, increased rates of depression, and overall a lower quality of life. People who have had strokes benefit from rehabilitative support to increase their independence and reduce the risk of stroke reoccurrence. Despite the gender differences in the effects of stroke, interventions explicitly aimed at helping women have not been identified. Purpose This systematic review aimed to summarize the effectiveness of the health promoting behavioural interventions for reducing risk factors and improved self-management in women post-stroke, compared to usual care. Method Seven databases, Medline (Ovid), CINAHL, PsychInfo, Embase, PubMed, Scopus, and Google Scholar, were reviewed for randomized controlled trials covering post-stroke interventions. The following keywords were used: health promotion, secondary prevention, woman, women, female, sex difference, gender difference, after stroke, and post-stroke. Results Ten randomised controlled trials were found. These demonstrated common successful approaches for rehabilitation, but none specifically described health promotion strategies for women. Core components of successful programs appeared to be a structured approach, tailored to clientele and formalised support systems through their carer, family networks, or community engagement. Comprehensive reminder systems were successful for stroke risk reduction. Conclusion Women are disproportionately affected by stroke and are often in the frail category. Tailored structured health promotion programs with family and caregiver support combined with a comprehensive reminder system would appear to enable women post-stroke.
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Affiliation(s)
- Karenza Taft
- Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Bobbi Laing
- Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Cynthia Wensley
- Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Lorraine Nielsen
- Te Tumu Herenga/Libraries & Learning Services, The University of Auckland, Auckland, New Zealand
| | - Julia Slark
- Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand
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Navarrro JC, Escabillas C, Aquino A, Macrohon C, Belen A, Abbariao M, Cuasay E, Lao A, Sarfati S, Hiyadan JH, Reyes FD, Salazar G, Dadgardoust P, De Leon-Gacrama F, Reandelar M. Stroke units in the Philippines: An observational study. Int J Stroke 2021; 16:849-854. [PMID: 33407015 DOI: 10.1177/1747493020981730] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In high-income countries, the management of stroke has changed substantially over the years with the advent of thrombolysis and endovascular treatment. However, in low-income countries, such interventions may not be available, or patients may come to the hospital outside the time window no longer qualified for this therapy. Most studies on stroke units were conducted in high-income countries. Unfortunately, there has been no local multicenter data with large patient numbers showing the effectiveness of stroke units in the Southeast Asian region. AIM To compare the outcomes of patients allocated to stroke units (based on accepted criteria) to those allocated to general neurology wards in the Philippines. METHODS This is an open, prospective, parallel, observational comparative study of patients from 11 institutions in the Philippines. Patients were allocated either to the stroke unit or to the general neurology ward by the admitting physician based on the criteria suggested by the Stroke Trialist Collaboration Group. The primary outcome was to determine in-hospital mortality at three- and six months in both stroke units and general neurology wards. The secondary outcomes were determined by a dichotomized modified Rankin scale: (0-2) independent and (3-5) dependent. RESULTS A total of 1025 patients were included in the study. In the primary outcome, a higher mortality rate (8.4% vs 1.0%) in the general neurology ward (p = 0.000) was seen. The six-month mortality rate was statistically significant and higher among patients admitted to the general neurology ward (3.1% vs 0.8%) (p = 0.009). Patients admitted to the stroke unit attained an independent functional outcome (mRS 0-2) as compared to the general neurology ward (73% vs 61.5%) (p = 0.000). Analysis of functionality at six months favored patients admitted in the stroke unit (88.5% vs 81.4%) as compared to the general neurology ward. CONCLUSION Patients specifically admitted to stroke units in the Philippines based on established criteria have better outcomes than those admitted to general neurology wards.
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Affiliation(s)
- Jose C Navarrro
- Department of Neurology, Jose R Reyes Memorial Medical Center, Manila City, Philippines.,St. Luke's Medical Center, Institute of Neurosciences, Quezon City, Philippines.,Department of Neurology and Psychiatry, University of Santo Tomas, Manila, Philippines
| | - Cyrus Escabillas
- Department of Neurology, Jose R Reyes Memorial Medical Center, Manila City, Philippines.,Dr Nicanor Reyes Memorial Foundation Far Eastern University, Quezon City, Philippines
| | - Abdias Aquino
- Department of Internal Medicine, Capitol Medical Center, Quezon City, Philippines
| | - Christina Macrohon
- St. Luke's Medical Center, Institute of Neurosciences, Quezon City, Philippines
| | - Allan Belen
- Community General Hospital of San Pablo City
| | - Maritoni Abbariao
- Department of Medicine, Dr. Jose Rodriguez Memorial Medical Hospital and Sanitarium, Caloocan City, Philippines
| | - Edna Cuasay
- Daniel Mercado Medical Center, Batangas, Philippines
| | - Annabelle Lao
- Department of Internal Medicine, Davao Medical School Foundation, Davao City, Philippines
| | | | | | - Fe Delos Reyes
- Department of Neurology, Baguio General Hospital Medical Center, Baguio City, Philippines
| | | | - Pariessa Dadgardoust
- Department of Neurology and Psychiatry, University of Santo Tomas, Manila, Philippines
| | | | - Macario Reandelar
- St. Luke's Medical Center, Institute of Neurosciences, Quezon City, Philippines.,Dr Nicanor Reyes Memorial Foundation Far Eastern University, Quezon City, Philippines
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Gooding PA, Pratt D, Awenat Y, Drake R, Elliott R, Emsley R, Huggett C, Jones S, Kapur N, Lobban F, Peters S, Haddock G. A psychological intervention for suicide applied to non-affective psychosis: the CARMS (Cognitive AppRoaches to coMbatting Suicidality) randomised controlled trial protocol. BMC Psychiatry 2020; 20:306. [PMID: 32546129 PMCID: PMC7298803 DOI: 10.1186/s12888-020-02697-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/27/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Suicide is a leading cause of death globally. Suicide deaths are elevated in those experiencing severe mental health problems, including schizophrenia. Psychological talking therapies are a potentially effective means of alleviating suicidal thoughts, plans, and attempts. However, talking therapies need to i) focus on suicidal experiences directly and explicitly, and ii) be based on testable psychological mechanisms. The Cognitive AppRoaches to coMbatting Suicidality (CARMS) project is a Randomised Controlled Trial (RCT) which aims to investigate both the efficacy and the underlying mechanisms of a psychological talking therapy for people who have been recently suicidal and have non-affective psychosis. METHODS The CARMS trial is a two-armed single-blind RCT comparing a psychological talking therapy (Cognitive Behavioural Suicide Prevention for psychosis [CBSPp]) plus Treatment As Usual (TAU) with TAU alone. There are primary and secondary suicidality outcome variables, plus mechanistic, clinical, and health economic outcomes measured over time. The primary outcome is a measure of suicidal ideation at 6 months after baseline. The target sample size is 250, with approximately 125 randomised to each arm of the trial, and an assumption of up to 25% attrition. Hence, the overall recruitment target is up to 333. An intention to treat analysis will be used with primary stratification based on National Health Service (NHS) recruitment site and antidepressant prescription medication. Recruitment will be from NHS mental health services in the North West of England, UK. Participants must be 18 or over; be under the care of mental health services; have mental health problems which meet ICD-10 non-affective psychosis criteria; and have experienced self-reported suicidal thoughts, plans, and/or attempts in the 3 months prior to recruitment. Nested qualitative work will investigate the pathways to suicidality, experiences of the therapy, and identify potential implementation challenges beyond a trial setting as perceived by numerous stake-holders. DISCUSSION This trial has important implications for countering suicidal experiences for people with psychosis. It will provide definitive evidence about the efficacy of the CBSPp therapy; the psychological mechanisms which lead to suicidal experiences; and provide an understanding of what is required to implement the intervention into services should it be efficacious. TRIAL REGISTRATION ClinicalTrials.gov (NCT03114917), 14th April 2017. ISRCTN (reference ISRCTN17776666 https://doi.org/10.1186/ISRCTN17776666); 5th June 2017). Registration was recorded prior to participant recruitment commencing.
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Affiliation(s)
- Patricia A Gooding
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Coupland Building 1, Oxford Road, Manchester, M13 9PL, UK.
- Greater Manchester Mental Health NHS Trust (formerly Manchester Mental Health and Social Care Trust), Manchester, UK.
| | - Daniel Pratt
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Coupland Building 1, Oxford Road, Manchester, M13 9PL, UK
- Greater Manchester Mental Health NHS Trust (formerly Manchester Mental Health and Social Care Trust), Manchester, UK
| | - Yvonne Awenat
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Coupland Building 1, Oxford Road, Manchester, M13 9PL, UK
- Greater Manchester Mental Health NHS Trust (formerly Manchester Mental Health and Social Care Trust), Manchester, UK
| | - Richard Drake
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Coupland Building 1, Oxford Road, Manchester, M13 9PL, UK
- Greater Manchester Mental Health NHS Trust (formerly Manchester Mental Health and Social Care Trust), Manchester, UK
| | - Rachel Elliott
- Manchester Centre for Health Economics, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Richard Emsley
- Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, UK
| | - Charlotte Huggett
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Coupland Building 1, Oxford Road, Manchester, M13 9PL, UK
- Greater Manchester Mental Health NHS Trust (formerly Manchester Mental Health and Social Care Trust), Manchester, UK
| | - Steven Jones
- Lancashire Care NHS Foundation Trust, Lancashire, UK
- University of Lancaster, Lancaster, UK
| | - Navneet Kapur
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Coupland Building 1, Oxford Road, Manchester, M13 9PL, UK
- Greater Manchester Mental Health NHS Trust (formerly Manchester Mental Health and Social Care Trust), Manchester, UK
| | - Fiona Lobban
- Lancashire Care NHS Foundation Trust, Lancashire, UK
- University of Lancaster, Lancaster, UK
| | - Sarah Peters
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Coupland Building 1, Oxford Road, Manchester, M13 9PL, UK
| | - Gillian Haddock
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Coupland Building 1, Oxford Road, Manchester, M13 9PL, UK
- Greater Manchester Mental Health NHS Trust (formerly Manchester Mental Health and Social Care Trust), Manchester, UK
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Beresford B, Mann R, Parker G, Kanaan M, Faria R, Rabiee P, Weatherly H, Clarke S, Mayhew E, Duarte A, Laver-Fawcett A, Aspinal F. Reablement services for people at risk of needing social care: the MoRe mixed-methods evaluation. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07160] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Reablement is an intensive, time-limited intervention for people at risk of needing social care or an increased intensity of care. Differing from home care, it seeks to restore functioning and self-care skills. In England, it is a core element of intermediate care. The existing evidence base is limited.
Objectives
To describe reablement services in England and develop a service model typology; to conduct a mixed-methods comparative evaluation of service models investigating outcomes, factors that have an impact on outcomes, costs and cost-effectiveness, and user and practitioner experiences; and to investigate specialist reablement services/practices for people with dementia.
Methods
Work package (WP) 1, which took place in 2015, surveyed reablement services in England. Data were collected on organisational characteristics, service delivery and practice, and service costs and caseload. WP2 was an observational study of three reablement services, each representing a different service model. Data were collected on health (EuroQol-5 Dimensions, five-level version) and social care related (Adult Social Care Outcomes Toolkit – self-completed) quality of life, practitioner (Barthel Index of Activities of Daily Living) and self-reported (Nottingham Extended Activities of Daily Living scale) functioning, individual and service characteristics, and resource use. They were collected on entry into reablement (n = 186), at discharge (n = 128) and, for those reaching the point on the study timeline, at 6 months post discharge (n = 64). Interviews with staff and service users explored experiences of delivering or receiving reablement and its perceived impacts. In WP3, staff in eight reablement services were interviewed to investigate their experiences of reabling people with dementia.
Results
A total of 201 services in 139 local authorities took part in the survey. Services varied in their organisational base, their relationship with other intermediate care services, their use of outsourced providers, their skill mix and the scope of their reablement input. These characteristics influenced aspects of service delivery and practice. The average cost per case was £1728. Lower than expected sample sizes meant that a comparison of service models in WP2 was not possible. The findings are preliminary. At discharge (T1), significant improvements in mean score on outcome measures, except self-reported functioning, were observed. Further improvements were observed at 6 months post discharge (T2), but these were significant for self-reported functioning only. There was some evidence that individual (e.g. engagement, mental health) and service (e.g. service structure) characteristics were associated with outcomes and resource use at T1. Staff’s views on factors affecting outcomes typically aligned with, or offered possible explanations for, these associations. However, it was not possible to establish the significance of these findings in terms of practice or commissioning decisions. Service users expressed satisfaction with reablement and identified two core impacts: regained independence and, during reablement, companionship. Staff participating in WP3 believed that people with dementia can benefit from reablement, but objectives may differ and expectations for regained independence may be inappropriate. Furthermore, staff believed that flexibility in practice (e.g. duration of home visits) should be incorporated into delivery models and adequate provision made for specialist training of staff.
Conclusions
The study contributes to our understanding of reablement, and what the impacts are on outcomes and costs. Staff believe that reablement can be appropriate for people with dementia. Findings will be of interest to commissioners and service managers. Future research should further investigate the factors that have an impact on outcomes, and reabling people with dementia.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
| | - Rachel Mann
- Social Policy Research Unit, University of York, York, UK
| | - Gillian Parker
- Social Policy Research Unit, University of York, York, UK
| | - Mona Kanaan
- Department of Health Sciences, University of York, York, UK
| | - Rita Faria
- Centre for Health Economics, University of York, York, UK
| | | | | | - Susan Clarke
- Social Policy Research Unit, University of York, York, UK
| | - Emese Mayhew
- Social Policy Research Unit, University of York, York, UK
| | - Ana Duarte
- Centre for Health Economics, University of York, York, UK
| | | | - Fiona Aspinal
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care North Thames, Institute of Epidemiology & Health, University College London, London, UK
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Fulop NJ, Ramsay AIG, Hunter RM, McKevitt C, Perry C, Turner SJ, Boaden R, Papachristou I, Rudd AG, Tyrrell PJ, Wolfe CDA, Morris S. Evaluation of reconfigurations of acute stroke services in different regions of England and lessons for implementation: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background
Centralising acute stroke services is an example of major system change (MSC). ‘Hub and spoke’ systems, consisting of a reduced number of services providing acute stroke care over the first 72 hours following a stroke (hubs), with a larger number of services providing care beyond this phase (spokes), have been proposed to improve care and outcomes.
Objective
To use formative evaluation methods to analyse reconfigurations of acute stroke services in different regions of England and to identify lessons that will help to guide future reconfigurations, by studying the following contrasting cases: (1) London (implemented 2010) – all patients eligible for Hyperacute Stroke Units (HASUs); patients admitted 24 hours a day, 7 days a week; (2) Greater Manchester A (GMA) (2010) – only patients presenting within 4 hours are eligible for HASU treatment; one HASU operated 24/7, two operated from 07.00 to 19.00, Monday to Friday; (3) Greater Manchester B (GMB) (2015) – all patients eligible for HASU treatment (as in London); one HASU operated 24/7, two operated with admission extended to the hours of 07.00–23.00, Monday to Sunday; and (4) Midlands and East of England – planned 2012/13, but not implemented.
Design
Impact was studied through a controlled before-and-after design, analysing clinical outcomes, clinical interventions and cost-effectiveness. The development, implementation and sustainability of changes were studied through qualitative case studies, documentation analysis (n = 1091), stakeholder interviews (n = 325) and non-participant observations (n = 92; ≈210 hours). Theory-based framework was used to link qualitative findings on process of change with quantitative outcomes.
Results
Impact – the London centralisation performed significantly better than the rest of England (RoE) in terms of mortality [–1.1%, 95% confidence interval (CI) –2.1% to –0.1%], resulting in an estimated additional 96 lives saved per year beyond reductions observed in the RoE, length of stay (LOS) (–1.4 days, 95% –2.3 to –0.5 days) and delivering effective clinical interventions [e.g. arrival at a Stroke Unit (SU) within 4 hours of ‘clock start’ (when clock start refers to arrival at hospital for strokes occurring outside hospital or the appearance of symptoms for patients who are already in-patients at the time of stroke): London = 66.3% (95% CI 65.6% to 67.1%); comparator = 54.4% (95% CI 53.6% to 55.1%)]. Performance was sustained over 6 years. GMA performed significantly better than the RoE on LOS (–2.0 days, 95% CI –2.8 to –1.2 days) only. GMB (where 86% of patients were treated in HASU) performed significantly better than the RoE on LOS (–1.5 days, 95% CI –2.5 to –0.4 days) and clinical interventions [e.g. SU within 4 hours: GMB = 79.1% (95% CI 77.9% to 80.4%); comparator = 53.4% (95% CI 53.0% to 53.7%)] but not on mortality (–1.3%, 95% CI –2.7% to 0.01%; p = 0.05, accounting for reductions observed in RoE); however, there was a significant effect when examining GMB HASUs only (–1.8%, 95% CI –3.4% to –0.2%), resulting in an estimated additional 68 lives saved per year. All centralisations except GMB were cost-effective at 10 years, with a higher net monetary benefit than the RoE at a willingness to pay for a quality-adjusted life-year (QALY) of £20,000–30,000. Per 1000 patients at 10 years, London resulted in an additional 58 QALYs, GMA resulted in an additional 18 QALYs and GMB resulted in an additional 6 QALYs at costs of £1,014,363, –£470,848 and £719,948, respectively. GMB was cost-effective at 90 days. Despite concerns about the potential impact of increased travel times, patients and carers reported good experiences of centralised services; this relied on clear information at every stage. Planning change – combining top-down authority and bottom-up clinical leadership was important in co-ordinating multiple stakeholders to agree service models and overcome resistance. Implementation – minimising phases of change, use of data, service standards linked to financial incentives and active facilitation of changes by stroke networks was important. The 2013 reforms of the English NHS removed sources of top-down authority and facilitative capacity, preventing centralisation (Midlands and East of England) and delaying implementation (GMB). Greater Manchester’s Operational Delivery Network, developed to provide alternative network facilitation, and London’s continued use of standards suggested important facilitators of centralisation in a post-reform context.
Limitations
The main limitation of our quantitative analysis was that we were unable to control for stroke severity. In addition, findings may not apply to non-urban settings. Data on patients’ quality of life were unavailable nationally, clinical interventions measured changed over time and national participation in audits varied. Some qualitative analyses were retrospective, potentially influencing participant views.
Conclusions
Centralising acute stroke services can improve clinical outcomes and care provision. Factors related to the service model implemented, how change is implemented and the context in which it is implemented are influential in improvement. We recommend further analysis of how different types of leadership contribute to MSC, patient and carer experience during the implementation of change, the impact of change on further clinical outcomes (disability and QoL) and influence of severity of stroke on clinical outcomes. Finally, our findings should be assessed in relation to MSC implemented in other health-care specialties.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
| | - Angus IG Ramsay
- Department of Applied Health Research, University College London, London, UK
| | - Rachael M Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Christopher McKevitt
- Department of Population Health Sciences, School of Population Health & Environmental Sciences Research, King’s College London, London, UK
| | - Catherine Perry
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Simon J Turner
- Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Ruth Boaden
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | | | - Anthony G Rudd
- Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK
| | - Pippa J Tyrrell
- Stroke and Vascular Centre, University of Manchester, Manchester Academic Health Science Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK
| | - Charles DA Wolfe
- Department of Population Health Sciences, School of Population Health & Environmental Sciences Research, King’s College London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
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10
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Perry C, Papachristou I, Ramsay AIG, Boaden RJ, McKevitt C, Turner SJ, Wolfe CDA, Fulop NJ. Patient experience of centralized acute stroke care pathways. Health Expect 2018; 21:909-918. [PMID: 29605966 PMCID: PMC6186538 DOI: 10.1111/hex.12685] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2018] [Indexed: 12/01/2022] Open
Abstract
Background In 2010, Greater Manchester (GM) and London centralized acute stroke care services into a reduced number of hyperacute stroke units, with local stroke units providing on‐going care nearer patients’ homes. Objective To explore the impact of centralized acute stroke care pathways on the experiences of patients. Design Qualitative interview study. Thematic analysis was undertaken, using deductive and inductive approaches. Final data analysis explored themes related to five chronological phases of the centralized stroke care pathway. Setting and participants Recruitment from 3 hospitals in GM (15 stroke patients/8 family members) and 4 in London (21 stroke patients/9 family members). Results Participants were impressed with emergency services and initial reception at hospital: disquiet about travelling further than a local hospital was allayed by clear explanations. Participants knew who was treating them and were involved in decisions. Difficulties for families visiting hospitals a distance from home were raised. Repatriation to local hospitals was not always timely, but no detrimental effects were reported. Discharge to the community was viewed less positively. Discussion and conclusions Patients on the centralized acute stroke care pathways reported many positive aspects of care: the centralization of care pathways can offer patients a good experience. Disadvantages of travelling further were perceived to be outweighed by the opportunity to receive the best quality care. This study highlights the necessity for all staff on a centralized care pathway to provide clear and accessible information to patients, in order to maximize their experience of care.
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Affiliation(s)
- Catherine Perry
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | | | - Angus I G Ramsay
- Department of Applied Health Research, University College London, London, UK
| | - Ruth J Boaden
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Christopher McKevitt
- Department of Primary Care and Public Health Sciences, Kings College London, London, UK.,National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
| | - Simon J Turner
- Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Charles D A Wolfe
- Department of Primary Care and Public Health Sciences, Kings College London, London, UK.,National Institute of Health Research Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK.,National Institute of Health Research, Collaboration for Leadership in Applied Health Research and Care South London, London, UK
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
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11
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Huntley AL, Chalder M, Shaw ARG, Hollingworth W, Metcalfe C, Benger JR, Purdy S. A systematic review to identify and assess the effectiveness of alternatives for people over the age of 65 who are at risk of potentially avoidable hospital admission. BMJ Open 2017; 7:e016236. [PMID: 28765132 PMCID: PMC5642761 DOI: 10.1136/bmjopen-2017-016236] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND/OBJECTIVES There are some older patients who are 'at the decision margin' of admission. This systematic review sought to explore this issue with the following objective: what admission alternatives are there for older patients and are they safe, effective and cost-effective? A secondary objective was to identify the characteristics of those older patients for whom the decision to admit to hospital may be unclear. DESIGN Systematic review of controlled studies (April 2005-December 2016) with searches in Medline, Embase, Cinahl and CENTRAL databases. The protocol is registered at PROSPERO (CRD42015020371). Studies were assessed using Cochrane risk of bias criteria, and relevant reviews were assessed with the AMSTAR tool. The results are presented narratively and discussed. SETTING Primary and secondary healthcare interface. PARTICIPANTS People aged over 65 years at risk of an unplanned admission. INTERVENTIONS Any community-based intervention offered as an alternative to admission to an acute hospital. PRIMARY AND SECONDARY OUTCOMES MEASURES Reduction in secondary care use, patient-related outcomes, safety and costs. RESULTS Nineteen studies and seven systematic reviews were identified. These recruited patients with both specific conditions and mixed chronic and acute conditions. The interventions involved paramedic/emergency care practitioners (n=3), emergency department-based interventions (n=3), community hospitals (n=2) and hospital-at-home services (n=11). Data suggest that alternatives to admission appear safe with potential to reduce secondary care use and length of time receiving care. There is a lack of patient-related outcomes and cost data. The important features of older patients for whom the decision to admit is uncertain are: age over 75 years, comorbidities/multi-morbidities, dementia, home situation, social support and individual coping abilities. CONCLUSIONS This systematic review describes and assesses evidence on alternatives to acute care for older patients and shows that many of the options available are safe and appear to reduce resource use. However, cost analyses and patient preference data are lacking.
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Affiliation(s)
- Alyson L Huntley
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Melanie Chalder
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
- Brunelcare, Saffron Gardens, Bristol, UK
| | - Ali R G Shaw
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - William Hollingworth
- Health Economics at Bristol, School of Social and Community Medicine University of Bristol, Bristol, UK
| | - Chris Metcalfe
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Jonathan Richard Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
- Department of Emergency Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Sarah Purdy
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
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12
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Walters SJ, Bonacho Dos Anjos Henriques-Cadby I, Bortolami O, Flight L, Hind D, Jacques RM, Knox C, Nadin B, Rothwell J, Surtees M, Julious SA. Recruitment and retention of participants in randomised controlled trials: a review of trials funded and published by the United Kingdom Health Technology Assessment Programme. BMJ Open 2017; 7:e015276. [PMID: 28320800 PMCID: PMC5372123 DOI: 10.1136/bmjopen-2016-015276] [Citation(s) in RCA: 289] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Substantial amounts of public funds are invested in health research worldwide. Publicly funded randomised controlled trials (RCTs) often recruit participants at a slower than anticipated rate. Many trials fail to reach their planned sample size within the envisaged trial timescale and trial funding envelope. OBJECTIVES To review the consent, recruitment and retention rates for single and multicentre randomised control trials funded and published by the UK's National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme. DATA SOURCES AND STUDY SELECTION HTA reports of individually randomised single or multicentre RCTs published from the start of 2004 to the end of April 2016 were reviewed. DATA EXTRACTION Information was extracted, relating to the trial characteristics, sample size, recruitment and retention by two independent reviewers. MAIN OUTCOME MEASURES Target sample size and whether it was achieved; recruitment rates (number of participants recruited per centre per month) and retention rates (randomised participants retained and assessed with valid primary outcome data). RESULTS This review identified 151 individually RCTs from 787 NIHR HTA reports. The final recruitment target sample size was achieved in 56% (85/151) of the RCTs and more than 80% of the final target sample size was achieved for 79% of the RCTs (119/151). The median recruitment rate (participants per centre per month) was found to be 0.92 (IQR 0.43-2.79) and the median retention rate (proportion of participants with valid primary outcome data at follow-up) was estimated at 89% (IQR 79-97%). CONCLUSIONS There is considerable variation in the consent, recruitment and retention rates in publicly funded RCTs. Investigators should bear this in mind at the planning stage of their study and not be overly optimistic about their recruitment projections.
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Affiliation(s)
- Stephen J Walters
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Oscar Bortolami
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Laura Flight
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Daniel Hind
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Richard M Jacques
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Christopher Knox
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ben Nadin
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Joanne Rothwell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Michael Surtees
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Steven A Julious
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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13
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Theofanidis D, Gibbon B. Exploring the experiences of nurses and doctors involved in stroke care: a qualitative study. J Clin Nurs 2016; 25:1999-2007. [DOI: 10.1111/jocn.13230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2016] [Indexed: 11/28/2022]
Affiliation(s)
| | - Bernard Gibbon
- Head of School of Health Sciences; University of Liverpool; Liverpool UK
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14
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Theofanidis D, Savopoulos C, Hatzitolios A. Global specialized stroke care delivery models. JOURNAL OF VASCULAR NURSING 2016; 34:2-11. [PMID: 26897346 DOI: 10.1016/j.jvn.2015.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 07/15/2015] [Accepted: 07/15/2015] [Indexed: 10/22/2022]
Abstract
Stroke services still vary enormously from country to country, with many countries providing no special services at all. The aim of this article is to provide a concise overview of the various types of acute stroke delivery systems at present available and critically describe merits and shortcomings. A systematic literature review was undertaken from 1990 to July 2014. Several models for stroke services have been developed mostly in the past 3 decades, mainly in the Western world. These include state-of-the-art stroke services ranging from highly specialized stroke centers to mobile stroke units for the community. In this light, the recommendations of the structure and organization of stroke units and stroke centers by the European Stroke Organization were recently published. What differentiates the various models of stroke care delivery across the globe is the diversity of services ranging from low key conventional care to highly sophisticated facilities with life saving interventional features via integrated stroke care infrastructure. Effective in-hospital care for stroke should start in the emergency department where a swift and appropriate diagnosis should be made. The role of all brain neuroimaging procedures should have a defined a priori and proper demarcation between actions according to updated stroke care pathways and clinical protocols, which should be followed closely. These essential actions initiated by well-trained staff in the emergency department, should then be carried on in dedicated stroke facilities that is, a stroke unit.
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Affiliation(s)
- Dimitrios Theofanidis
- Nursing Department, Alexandreio Technological Educational Institute of Thesaloniki, Thessaloniki, Greece.
| | - Christos Savopoulos
- First Propedeutic Department of Internal Medicine, Medical School, "AHEPA" University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Hatzitolios
- First Propedeutic Department of Internal Medicine, Medical School, "AHEPA" University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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15
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Is cost effectiveness sustained after weekend inpatient rehabilitation? 12 month follow up from a randomized controlled trial. BMC Health Serv Res 2015; 15:165. [PMID: 25927870 PMCID: PMC4438580 DOI: 10.1186/s12913-015-0822-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 03/26/2015] [Indexed: 11/28/2022] Open
Abstract
Background Our previous work showed that providing additional rehabilitation on a Saturday was cost effective in the short term from the perspective of the health service provider. This study aimed to evaluate if providing additional rehabilitation on a Saturday was cost effective at 12 months, from a health system perspective inclusive of private costs. Methods Cost effectiveness analyses alongside a single-blinded randomized controlled trial with 12 months follow up inclusive of informal care. Participants were adults admitted to two publicly funded inpatient rehabilitation facilities. The control group received usual care rehabilitation services from Monday to Friday and the intervention group received usual care plus additional Saturday rehabilitation. Incremental cost effectiveness ratios were reported as cost per quality adjusted life year (QALY) gained and for a minimal clinical important difference (MCID) in functional independence. Results A total of 996 patients [mean age 74 years (SD 13)] were randomly assigned to the intervention (n = 496) or control group (n = 500). The intervention was associated with improvements in QALY and MCID in function, as well as a non-significant reduction in cost from admission to 12 months (mean difference (MD) AUD$6,325; 95% CI −4,081 to 16,730; t test p = 0.23 and MWU p = 0.06), and a significant reduction in cost from admission to 6 months (MD AUD$6,445; 95% CI 3,368 to 9,522; t test p = 0.04 and MWU p = 0.01). There is a high degree of certainty that providing additional rehabilitation services on Saturday is cost effective. Sensitivity analyses varying the cost of informal carers and self-reported health service utilization, favored the intervention. Conclusions From a health system perspective inclusive of private costs the provision of additional Saturday rehabilitation for inpatients is likely to have sustained cost savings per QALY gained and for a MCID in functional independence, for the inpatient stay and 12 months following discharge, without a cost shift into the community. Trial registration Australian and New Zealand Clinical Trials Registry November 2009 ACTRN12609000973213. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-0822-3) contains supplementary material, which is available to authorized users.
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16
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Hewitt G, Sims S, Greenwood N, Jones F, Ross F, Harris R. Interprofessional teamwork in stroke care: Is it visible or important to patients and carers? J Interprof Care 2014; 29:331-9. [PMID: 25158116 DOI: 10.3109/13561820.2014.950727] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Interprofessional teamwork is seen in healthcare policy and practice as a key strategy for providing safe, efficient and holistic healthcare and is an accepted part of evidence-based stroke care. The impact of interprofessional teamwork on patient and carer experience(s) of care is unknown, although some research suggests a relationship might exist. This study aimed to explore patient and carer perceptions of good and poor teamwork and its impact on experiences of care. Critical incident interviews were conducted with 50 patients and 33 carers in acute, inpatient rehabilitation and community phases of care within two UK stroke care pathways. An analytical framework, derived from a realist synthesis of 13 'mechanisms' (processes) of interprofessional teamwork, was used to identify positive and negative 'indicators' of teamwork. Participants identified several mechanisms of teamwork, but it was not a subject most talked about readily. This suggests that interprofessional teamwork is not a concept that is particularly important to stroke patients and carers; they do not readily perceive any impacts of teamwork on their experiences. These findings are a salient reminder that what might be expected by healthcare professionals to be important influences on experience may not be perceived to be so by patients and carers.
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Affiliation(s)
- Gillian Hewitt
- Cardiff School of Social Sciences, Cardiff University , Cardiff , UK and
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17
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Brusco NK, Taylor NF, Watts JJ, Shields N. Economic Evaluation of Adult Rehabilitation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials in a Variety of Settings. Arch Phys Med Rehabil 2014; 95:94-116.e4. [DOI: 10.1016/j.apmr.2013.03.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 03/14/2013] [Accepted: 03/14/2013] [Indexed: 12/01/2022]
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18
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Schnitzler A, Woimant F, Nicolau J, Tuppin P, de Peretti C. Effect of Rehabilitation Setting on Dependence Following Stroke. Neurorehabil Neural Repair 2013; 28:36-44. [DOI: 10.1177/1545968313497828] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. In France in 2009, patients admitted to Multidisciplinary Inpatient Rehabilitation for stroke were sent to a neurological rehabilitation center (NRC) or a general or geriatric rehabilitation (GRC) service. Objective. To describe the functional outcome of stroke patients admitted for rehabilitation in France in 2009, both globally and as a function of the rehabilitation setting (GRC or NRC). Methods. Data from the French Hospital Discharge Diagnosis databases for 2009 were included. Two logistic regression models were used to analyze factors related to improvement in dependence score and discharge home. Odds ratios (ORs) were also calculated. Results. Among the 83 505 survivors of acute stroke in 2009, 28 201 were admitted for rehabilitation (33.8%). Of these, 19 553 went to GRC (69%) and 8648 to NRC (31%). On average, patients admitted to GRC were older (78.6 years vs 66.4 years), P < .001). At the start of rehabilitation, 50% of NRC patients and 56% of GRC patients were heavily dependent, but level of dependence was similar within each age-group. Rehabilitation in NRC lead to a greater probability of functional improvement (OR = 1.75, P < .001) and home discharge (OR = 1.61, P < .001) after adjustment for gender, age, Charlson’s comorbidity index, initial level of dependence, type of stroke, and total length of stay. Conclusion. This study confirms, on a national level, the functional benefit of specialized rehabilitation in NRC. These results should be useful in the improvement of care pathways, organization of rehabilitation, and discharge planning.
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Affiliation(s)
- Alexis Schnitzler
- Raymond Poincaré Hospital, AP-HP, University of Versailles Saint Quentin, Garches, France
| | - France Woimant
- Agence régionale de santé d’Ile de France, hôpital Lariboisière, Paris, France
| | - Javier Nicolau
- Institut de veille sanitaire, Saint-Maurice Cedex, France
| | - Philippe Tuppin
- Caisse nationale d’assurance maladie des travailleurs salariés, Paris Cedex, France
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19
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Langhammer B, Verheyden G. Stroke Rehabilitation: Issues for Physiotherapy and Physiotherapy Research to Improve Life after Stroke. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2013; 18:65-9. [DOI: 10.1002/pri.1553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | - Geert Verheyden
- Department of Rehabilitation Sciences; University of Leuven; Leuven Belgium
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20
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Impact of implementing evidence-based acute stroke interventions on survival: the South London Stroke Register. PLoS One 2013; 8:e61581. [PMID: 23634211 PMCID: PMC3636277 DOI: 10.1371/journal.pone.0061581] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 03/11/2013] [Indexed: 11/24/2022] Open
Abstract
Background Studies examining the impact of organised acute stroke care interventions on survival in subgroups of stroke patients remain limited. Aims This study examined the effects of a range of evidence-based interventions of acute stroke care on one year survival post-stroke and determined the size of the effect across different socio-demographic and clinical subgroups of patients. Methods Data on 4026 patients with a first-ever stroke recruited to the population-based South London Stroke Register between 1995 and 2010 were used. In uni-variable analyses, one year cumulative survival rates in socio-demographic groups and by care received was determined. Survival functions were compared using Log-rank tests. Multivariable Cox models were used to test for interactions between components of care and age group, sex, ethnic group, social class, stroke subtype and level of consciousness. Results 1949 (56.4%) patients were admitted to a stroke unit. Patients managed on a stroke unit, those with deficits receiving specific rehabilitation therapies and those with ischaemic stroke subtype receiving aspirin in the acute phase had better one year survival compared to those who did not receive these interventions. The greatest reduction in the hazards of death among patients treated on a stroke unit were in the youngest patients aged <65 years, (HR 0.39; 95% CI: 0.25–0.62), and those with reduced levels of consciousness, GCS <9, (HR: 0.44; CI: 0.33–0.58). Conclusions There was evidence of better one year survival in patients receiving specific acute interventions after stroke with a significantly greater effect in stroke subgroups, suggesting the possibility of re-organising stroke services to ensure that the most appropriate care is made accessible to patients likely to derive the most benefits from such interventions.
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21
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TRANSCATHETER AORTIC VALVE IMPLANTATION FOR SEVERE AORTIC STENOSIS: THE COST-EFFECTIVENESS CASE FOR INOPERABLE PATIENTS IN THE UNITED KINGDOM. Int J Technol Assess Health Care 2013; 29:12-9. [DOI: 10.1017/s0266462312000670] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Aortic stenosis (AS) is caused by age-related calcific degeneration of the aortic valve (1). Initially, cases are asymptomatic but, from the point that symptoms first develop, there is rapid progression and if left untreated survival estimates are low (2–3 years) (1). Therefore, managing AS effectively and efficiently is a priority for health systems with increasing healthcare costs and longer life expectancy.
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22
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Chan DKY, Cordato D, O'Rourke F, Chan DL, Pollack M, Middleton S, Levi C. Comprehensive Stroke Units: A Review of Comparative Evidence and Experience. Int J Stroke 2012; 8:260-4. [DOI: 10.1111/j.1747-4949.2012.00850.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Stroke unit care offers significant benefits in survival and dependency when compared to general medical ward. Most stroke units are either acute or rehabilitation, but comprehensive (combined acute and rehabilitation) model (comprehensive stroke unit) is less common. Aim To examine different levels of evidence of comprehensive stroke unit compared to other organized inpatient stroke care and share local experience of comprehensive stroke units. Methods Cochrane Library and Medline (1980 to December 2010) review of English language articles comparing stroke units to alternative forms of stroke care delivery, different types of stroke unit models, and differences in processes of care within different stroke unit models. Different levels of comparative evidence of comprehensive stroke units to other models of stroke units are collected. Results There are no randomized controlled trials directly comparing comprehensive stroke units to other stroke unit models (either acute or rehabilitation). Comprehensive stroke units are associated with reduced length of stay and greatest reduction in combined death and dependency in a meta-analysis study when compared to other stroke unit models. Comprehensive stroke units also have better length of stay and functional outcome when compared to acute or rehabilitation stroke unit models in a cross-sectional study, and better length of stay in a ‘before-and-after’ comparative study. Components of stroke unit care that improve outcome are multifactorial and most probably include early mobilization. A comprehensive stroke unit model has been successfully implemented in metropolitan and rural hospital settings. Conclusions Comprehensive stroke units are associated with reductions in length of stay and combined death and dependency and improved functional outcomes compared to other stroke unit models. A comprehensive stroke unit model is worth considering as the preferred model of stroke unit care in the planning and delivery of metropolitan and rural stroke services.
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Affiliation(s)
- Daniel K. Y. Chan
- Faculty of Medicine, University of New South Wales, New South Wales, Australia
- Department of Aged Care, Stroke & Rehabilitation, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
| | - Dennis Cordato
- Faculty of Medicine, University of New South Wales, New South Wales, Australia
- Department of Neurology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Fintan O'Rourke
- Department of Aged Care, Stroke & Rehabilitation, Bankstown-Lidcombe Hospital, Bankstown, New South Wales, Australia
| | - Daniel L Chan
- Faculty of Medicine, University of New South Wales, New South Wales, Australia
| | - Michael Pollack
- Hunter Stroke Service, Rankin Park Centre, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's & Mater Health Sydney – Australian Catholic University, Sydney, Australia
- National Centre for Clinical Outcomes Research (NaCCOR), St Vincent's Hospital, Australian Catholic University, Darlinghurst, New South Wales, Australia
| | - Chris Levi
- Acute Stroke Services, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
- Hunter Medical Research Institute (HMRI) Stroke Research Group, New Lambton Heights, New South Wales, Australia
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Panella M, Marchisio S, Brambilla R, Vanhaecht K, Di Stanislao F. A cluster randomized trial to assess the effect of clinical pathways for patients with stroke: results of the clinical pathways for effective and appropriate care study. BMC Med 2012; 10:71. [PMID: 22781160 PMCID: PMC3403956 DOI: 10.1186/1741-7015-10-71] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Accepted: 07/10/2012] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Clinical pathways (CPs) are used to improve the outcomes of acute stroke, but their use in stroke care is questionable, because the evidence on their effectiveness is still inconclusive. The objective of this study was to evaluate whether CPs improve the outcomes and the quality of care provided to patients after acute ischemic stroke. METHODS This was a multicentre cluster-randomized trial, in which 14 hospitals were randomized to the CP arm or to the non intervention/usual care (UC) arm. Healthcare workers in the CP arm received 3 days of training in quality improvement of CPs and in use of a standardized package including information on evidence-based key interventions and indicators. Healthcare workers in the usual-care arm followed their standard procedures. The teams in the CP arm developed their CPs over a 6-month period. The primary end point was mortality. Secondary end points were: use of diagnostic and therapeutic procedures, implementation of organized care, length of stay, re-admission and institutionalization rates after discharge, dependency levels, and complication rates. RESULTS Compared with the patients in the UC arm, the patients in the CP arm had a significantly lower risk of mortality at 7 days (OR = 0.10; 95% CI 0.01 to 0.95) and significantly lower rates of adverse functional outcomes, expressed as the odds of not returning to pre-stroke functioning in their daily life (OR = 0.42; 95 CI 0.18 to 0.98). There was no significant effect on 30-day mortality. Compared with the UC arm, the hospital diagnostic and therapeutic procedures were performed more appropriately in the CP arm, and the evidence-based key interventions and organized care were more applied in the CP arm. CONCLUSIONS CPs can significantly improve the outcomes of patients with ischemic patients with stroke, indicating better application of evidence-based key interventions and of diagnostic and therapeutic procedures. This study tested a new hypothesis and provided evidence on how CPs can work. TRIAL REGISTRATION ClinicalTrials.gov ID: [NCT00673491].
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Affiliation(s)
- Massimiliano Panella
- Department of Clinical and Experimental Medicine, University of Eastern Piedmont, Novara, Italy.
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Alvarez-Sabín J, Ribó M, Masjuan J, Tejada J, Quintana M. Hospital care of stroke patients: Importance of expert neurological care. NEUROLOGÍA (ENGLISH EDITION) 2011. [DOI: 10.1016/j.nrleng.2010.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Alvarez-Sabín J, Ribó M, Masjuan J, Tejada J, Quintana M. Importancia de una atención neurológica especializada en el manejo intrahospitalario de pacientes con ictus. Neurologia 2011; 26:510-7. [DOI: 10.1016/j.nrl.2010.12.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Accepted: 12/10/2010] [Indexed: 11/25/2022] Open
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Te Ao BJ, Brown PM, Feigin VL, Anderson CS. Are stroke units cost effective? Evidence from a New Zealand stroke incidence and population-based study. Int J Stroke 2011; 7:623-30. [PMID: 22010968 DOI: 10.1111/j.1747-4949.2011.00632.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIM Acute stroke units in hospitals are known to be more costly than standard care, but proponents claim that the health gains will justify the expense. Yet, despite widespread adoption of stroke units, the evidence on the cost effectiveness of stroke units has been mixed, due in part to differences in the pathway of care across hospitals. The purpose of this study is to compare costs and outcomes for patients admitted to a stroke unit with those admitted to a general ward. METHODS Data on 530 stroke sufferers from a large incidence study of stroke (the Auckland Regional Community Stroke Outcome Study) were used. Cost of health services, places of discharge were identified at one-, six- and 12 months poststroke and were linked with long-term cost and survival five-years poststroke. A decision analytical model was developed, including the relationship between waiting time for discharge and probability of admission to stroke unit. Cost effectiveness was determined using a willingness to pay threshold of NZ$20 000 (US$15 234). RESULTS Regression analysis suggested that there were no significant differences between patients admitted to a stroke unit and a general ward. The incremental cost-utility ratio for the first-year was NZ$42 813/quality-adjusted life year (US$32 610/quality-adjusted life year), but fell substantially to NZ$6747/quality-adjusted life year (US$5139/quality-adjusted life year) when lifetime costs and outcomes were considered. Probabilistic and one-way sensitivity analysis suggests that the results are robust to areas of uncertainty or delays in the pathway of care. CONCLUSION Stroke unit care was cost effective in Auckland, New Zealand.
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Affiliation(s)
- Braden J Te Ao
- National Institute for Stroke and Applied Neurosciences, School of Rehabilitation and Occupational Studies, School of Public Health and Psychosocial Studies, Auckland University of Technology, Auckland, New Zealand.
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Matthews GA, Dumville JC, Hewitt CE, Torgerson DJ. Retrospective cohort study highlighted outcome reporting bias in UK publicly funded trials. J Clin Epidemiol 2011; 64:1317-24. [PMID: 21889307 DOI: 10.1016/j.jclinepi.2011.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 02/25/2011] [Accepted: 03/22/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess outcome reporting bias and dissemination bias in trials funded by the National Health System (NHS) Health Technology Assessment (HTA) program. STUDY DESIGN AND SETTING A retrospective cohort study of HTA monographs and corresponding journal publications including all clinical effectiveness randomized controlled trials published as HTA monographs between 1999 and 2005 by the NHS HTA program. RESULTS There was a higher median P-value (P=0.33, interquartile range [IQR]: 0.02-0.54) among trials without a journal publication compared with those with a journal publication (P=0.14, IQR: 0.007-0.43), although the difference was not statistically significant (Mann-Whitney U test, z=-0.70; P=0.48). A higher proportion of statistically significant findings were reported in journal articles when compared with the outcomes reported in the HTA monographs. Trials published in general medical journals tended to have smaller P-values (median: 0.05, IQR: 0.001-0.22) than those published in more specialist journals (median: 0.33 IQR: 0.008-0.58), although this result was not significant (Mann-Whitney U test, z=-1.63; P=0.10). CONCLUSIONS Among journal-published trials, there were a greater proportion of statistically significant findings included in the journal reports compared with those in the HTA monographs.
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Bonaiuti D, Sioli P, Fumagalli L, Beghi E, Agostoni E. Acute medical complications in patients admitted to a stroke unit and safe transfer to rehabilitation. Neurol Sci 2011; 32:619-23. [PMID: 21533563 DOI: 10.1007/s10072-011-0588-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 04/07/2011] [Indexed: 10/18/2022]
Abstract
Acute medical complications often prevent patients with stroke from being transferred from stroke units to rehabilitation units, prolonging the occupation of hospital beds and delaying the start of intensive rehabilitation. This study defined incidence, timing, duration and risk factors of these complications during the acute phase of stroke. A retrospective case note review was made of hospital admissions of patients with stroke not associated with other disabling conditions, admitted to a stroke unit over 12 months and requiring rehabilitation for gait impairment. In this cohort, a search was made of hypertension, oxygen de-saturation, fever, and cardiac and pulmonary symptoms requiring medical intervention. Included were 135 patients. Hypertension was the most common complication (16.3%), followed by heart disease (14.8%), oxygen de-saturation (7.4%), fever (6.7%) and pulmonary disease (5.2%). Heart disease was the earliest and shortest complication. Most complications occurred during the first week. Except for hypertension, all complications resolved within 2 weeks.
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Affiliation(s)
- Donatella Bonaiuti
- Physical Medicine and Rehabilitation Department, S. Gerardo Hospital, Monza, Italy
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Ridyard CH, Hughes DA. Methods for the collection of resource use data within clinical trials: a systematic review of studies funded by the UK Health Technology Assessment program. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2010; 13:867-72. [PMID: 20946187 DOI: 10.1111/j.1524-4733.2010.00788.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND The UK Health Technology Assessment (HTA) program funds trials that address issues of clinical and cost-effectiveness to meet the needs of the National Health Service (NHS). The objective of this review was to systematically assess the methods of resource use data collection and costing; and to produce a best practice guide for data capture within economic analyses alongside clinical trials. METHODS All 100 HTA-funded primary research papers published to June 2009 were reviewed for the health economic methods employed. Data were extracted and summarized by: health technology assessed, costing perspective adopted, evidence of planning and piloting, data collection method, frequency of data collection, and sources of unit cost data. RESULTS Ninety-five studies were identified as having conducted an economic analysis, of which 85 recorded patient-level resource use. The review identified important differences in how data are collected. These included: a priori evidence of analysts having identified important cost drivers; the piloting and validation of patient-completed resource use questionnaires; choice of costing perspective; and frequency of data collection. Areas of commonality included: the extensive use of routine medical records and reliance on patient recall; and the use of standard sources of unit costs. CONCLUSION Economic data collection is variable, even among a homogeneous selection of trials designed to meet the needs of a common organization (NHS). Areas for improvement have been identified, and based on our findings and related reviews and guidelines, a checklist is proposed for good practice relating to economic data collection within clinical trials.
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Affiliation(s)
- Colin H Ridyard
- Centre for Economics & Policy in Health, Institute of Medical and Social Care Research, Bangor University, Bangor, Gwynedd, UK
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Ali M, Ashburn A, Bowen A, Brodie E, Corr S, Drummond A, Edmans J, Gladman J, Kalra L, Langhorne P, Lees KR, Lincoln N, Logan P, Mead G, Patchick E, Pollock A, Pomeroy V, Sackley C, Sunnerhagen KS, van Vliet P, Walker M, Brady M. VISTA-Rehab: A Resource for Stroke Rehabilitation Trials. Int J Stroke 2010; 5:447-52. [DOI: 10.1111/j.1747-4949.2010.00485.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background Stroke rehabilitation is a complex intervention. Many factors influence the interaction between the patient and the elements of the intervention. Rehabilitation interventions are aimed at altering different domains of patient outcome including body functions, activity and participation. As a consequence, randomised clinical trials in this area are difficult to design. We developed an archive of stroke rehabilitation trials (VISTA-Rehab) to act as a resource to help trialists model and design future rehabilitation studies. Methods We developed specific eligibility criteria for the entry of stroke rehabilitation trials into the archive. We established a Steering Committee to oversee projects and publications and commenced the recruitment of rehabilitation trials into this resource. Results As of August 2009, VISTA-Rehab contains data from 23 stroke rehabilitation trials (>3400 patients). Demographic data, including age [median=73, interquartile range (63,79)], gender (male=53%) and initial dependency [median baseline Barthel index score=6, interquartile range ( 9 , 19 )], are available for all patients. Outcome measures include the modified Rankin Scale, Barthel Index, Rivermead Motor Assessment, Fugl-Meyer Assessment, General Health Questionnaire and Nottingham Extended Activities of Daily Living Scale. Conclusion VISTA-Rehab expands the Virtual International Stroke Trials Archive to include rehabilitation trials. Anonymised data can be used to examine questions specific to stroke rehabilitation and to generate novel hypotheses.
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Affiliation(s)
- Myzoon Ali
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Ann Ashburn
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Audrey Bowen
- School of Psychological Sciences, University of Manchester, Manchester, UK
| | - Eric Brodie
- Department of Psychology, Glasgow Caledonian University, Glasgow, UK
| | - Susan Corr
- Division of Occupational Therapy University of Northampton, Northampton, UK
| | - Avril Drummond
- School of Community Health Sciences, University of Nottingham, Nottingham, UK
| | - Judi Edmans
- School of Community Health Sciences, University of Nottingham, Nottingham, UK
| | - John Gladman
- School of Community Health Sciences, University of Nottingham, Nottingham, UK
| | | | - Peter Langhorne
- Academic Section of Geriatric Medicine, Glasgow Royal Infirmary and Faculty of Medicine, University of Glasgow, Glasgow, UK
| | - Kennedy R. Lees
- VISTA Chairman, Institute of Cardiovascular and Medical Sciences, Faculty of Medicine, University of Glasgow, Glasgow, UK
| | - Nadina Lincoln
- Institute of Work, Health and Organisations, University of Nottingham, Nottingham, UK
| | - Pip Logan
- School of Community Health Sciences, University of Nottingham, Nottingham, UK
| | - Gillian Mead
- Clinical Sciences & Community Health, University of Edinburgh, Edinburgh, UK
| | - Emma Patchick
- School of Psychological Sciences, University of Manchester, Manchester, UK
| | - Alex Pollock
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Val Pomeroy
- Health and Social Sciences Research Institute, University of East Anglia, Norwich, UK
| | | | - Katherina S. Sunnerhagen
- Section for Clinical Neuroscience and Rehabilitation, University of Gothenburg, Gothenburg, Sweden
| | - Paulette van Vliet
- Division of Physiotherapy Education, School of Nursing, Midwifery and Physiotherapy, University of Nottingham
| | - Marion Walker
- School of Community Health Sciences, University of Nottingham, Nottingham, UK
| | - Marian Brady
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
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Murie-Fernández M, Irimia P, Martínez-Vila E, John Meyer M, Teasell R. Neuro-rehabilitation after stroke. NEUROLOGÍA (ENGLISH EDITION) 2010. [DOI: 10.1016/s2173-5808(10)70036-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2009:CD000072. [PMID: 19588316 DOI: 10.1002/14651858.cd000072.pub2] [Citation(s) in RCA: 430] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Poor interprofessional collaboration (IPC) can negatively affect the delivery of health services and patient care. Interventions that address IPC problems have the potential to improve professional practice and healthcare outcomes. OBJECTIVES To assess the impact of practice-based interventions designed to change IPC, compared to no intervention or to an alternate intervention, on one or more of the following primary outcomes: patient satisfaction and/or the effectiveness and efficiency of the health care provided. Secondary outcomes include the degree of IPC achieved. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care Group Specialised Register (2000-2007), MEDLINE (1950-2007) and CINAHL (1982-2007). We also handsearched the Journal of Interprofessional Care (1999 to 2007) and reference lists of the five included studies. SELECTION CRITERIA Randomised controlled trials of practice-based IPC interventions that reported changes in objectively-measured or self-reported (by use of a validated instrument) patient/client outcomes and/or health status outcomes and/or healthcare process outcomes and/or measures of IPC. DATA COLLECTION AND ANALYSIS At least two of the three reviewers independently assessed the eligibility of each potentially relevant study. One author extracted data from and assessed risk of bias of included studies, consulting with the other authors when necessary. A meta-analysis of study outcomes was not possible given the small number of included studies and their heterogeneity in relation to clinical settings, interventions and outcome measures. Consequently, we summarised the study data and presented the results in a narrative format. MAIN RESULTS Five studies met the inclusion criteria; two studies examined interprofessional rounds, two studies examined interprofessional meetings, and one study examined externally facilitated interprofessional audit. One study on daily interdisciplinary rounds in inpatient medical wards at an acute care hospital showed a positive impact on length of stay and total charges, but another study on daily interdisciplinary rounds in a community hospital telemetry ward found no impact on length of stay. Monthly multidisciplinary team meetings improved prescribing of psychotropic drugs in nursing homes. Videoconferencing compared to audioconferencing multidisciplinary case conferences showed mixed results; there was a decreased number of case conferences per patient and shorter length of treatment, but no differences in occasions of service or the length of the conference. There was also no difference between the groups in the number of communications between health professionals recorded in the notes. Multidisciplinary meetings with an external facilitator, who used strategies to encourage collaborative working, was associated with increased audit activity and reported improvements to care. AUTHORS' CONCLUSIONS In this updated review, we found five studies (four new studies) that met the inclusion criteria. The review suggests that practice-based IPC interventions can improve healthcare processes and outcomes, but due to the limitations in terms of the small number of studies, sample sizes, problems with conceptualising and measuring collaboration, and heterogeneity of interventions and settings, it is difficult to draw generalisable inferences about the key elements of IPC and its effectiveness. More rigorous, cluster randomised studies with an explicit focus on IPC and its measurement, are needed to provide better evidence of the impact of practice-based IPC interventions on professional practice and healthcare outcomes. These studies should include qualitative methods to provide insight into how the interventions affect collaboration and how improved collaboration contributes to changes in outcomes.
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Affiliation(s)
- Merrick Zwarenstein
- Continuing Education, University of Toronto, Senior Scientist, Institute for Clinical Evaluative Sciences, Room G1 06, 1075 Bayview Ave, Toronto, ON, Canada, M4N 3M5
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Evaluation of costs and outcome in cardioembolic stroke or TIA. J Neurol 2009; 256:954-63. [DOI: 10.1007/s00415-009-5053-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Revised: 12/19/2008] [Accepted: 01/13/2009] [Indexed: 10/21/2022]
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Assessing the impact of England's National Health Service R&D Health Technology Assessment program using the “payback” approach. Int J Technol Assess Health Care 2009; 25:1-5. [DOI: 10.1017/s0266462309090011] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Objectives:This study assesses the impact of the English National Health Service (NHS) Health Technology Assessment (HTA) program using the “payback” framework.Methods:A survey of lead investigators of all research projects funded by the HTA program 1993–2003 supplemented by more detailed case studies of sixteen projects.Results:Of 204 eligible projects, replies were received from 133 or 65 percent. The mean number of peer-reviewed publications per project was 2.9. Seventy-three percent of projects claimed to have had had an impact on policy and 42 percent on behavior. Technology Assessment Reports for the National Institute for Health and Clinical Excellence (NICE) had fewer than average publications but greater impact on policy. Half of all projects went on to secure further funding. The case studies confirmed the survey findings and indicated factors associated with impact.Conclusions:The HTA program performed relatively well in terms of “payback.” Facilitating factors included the program's emphasis on topics that matter to the NHS, rigorous methods and the existence of “policy customers” such as NICE.
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Campbell-Taylor I. Oropharyngeal dysphagia in long-term care: misperceptions of treatment efficacy. J Am Med Dir Assoc 2008; 9:523-31. [PMID: 18755427 DOI: 10.1016/j.jamda.2008.06.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2007] [Revised: 05/27/2008] [Accepted: 06/04/2008] [Indexed: 01/25/2023]
Abstract
The assessment and management of patients in long-term care who have oropharyngeal dysphagia has developed into an apparently complex and distinct field of practice. It is unfortunate that it lacks an evidence base, the efficacy of treatment is not established, and many clinicians are unfamiliar with appropriate and effective interventions because of a lack of training. Some commonly used interventions are not only ineffective but potentially hazardous. Physicians must become more familiar with the assessment process and appropriate management.
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Panella M, Marchisio S, Barbieri A, Di Stanislao F. A cluster randomized trial to assess the impact of clinical pathways for patients with stroke: rationale and design of the Clinical Pathways for Effective and Appropriate Care Study [NCT00673491]. BMC Health Serv Res 2008; 8:223. [PMID: 18980664 PMCID: PMC2585086 DOI: 10.1186/1472-6963-8-223] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Accepted: 11/03/2008] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patients with stroke should have access to a continuum of care from organized stroke units in the acute phase, to appropriate rehabilitation and secondary prevention measures. Moreover to improve the outcomes for acute stroke patients from an organizational perspective, the use of multidisciplinary teams and the delivery of continuous stroke education both to the professionals and to the public, and the implementation of evidence-based stroke care are recommended. Clinical pathways are complex interventions that can be used for this purpose. However in stroke care the use of clinical pathways remains questionable because little prospective controlled data has demonstrated their effectiveness. The purpose of this study is to determine whether clinical pathways could improve the quality of the care provided to the patients affected by stroke in hospital and through the continuum of the care. METHODS Two-arm, cluster-randomized trial with hospitals and rehabilitation long-term care facilities as randomization units. 14 units will be randomized either to arm 1 (clinical pathway) or to arm 2 (no intervention, usual care). The sample will include 238 in each group, this gives a power of 80%, at 5% significance level. The primary outcome measure is 30-days mortality. The impact of the clinical pathways along the continuum of care will also be analyzed by comparing the length of hospital stay, the hospital re-admissions rates, the institutionalization rates after hospital discharge, the patients' dependency levels, and complication rates. The quality of the care provided to the patients will be assessed by monitoring the use of diagnostic and therapeutic procedures during hospital stay and rehabilitation, and by the use of key quality indicators at discharge. The implementation of organized care will be also evaluated. CONCLUSION The management of patients affected by stroke involves the expertise of several professionals, which can result in poor coordination or inefficiencies in patient treatment, and clinical pathways can significantly improve the outcomes of these patients. It is proposed that this study will test a new hypothesis and provide evidence of how clinical pathways can work. TRIAL REGISTRATION ClinicalTrials.gov ID [NCT00673491].
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Affiliation(s)
- Massimiliano Panella
- Department of Clinical and Experimental Medicine, University of Eastern Piedmont "A. Avogadro", Novara, Italy
| | - Sara Marchisio
- Department of Clinical and Experimental Medicine, University of Eastern Piedmont "A. Avogadro", Novara, Italy
- Department of Hygiene and Public Health, University "Politecnica delle Marche", Ancona, Italy
| | - Antonella Barbieri
- Department of Clinical and Experimental Medicine, University of Eastern Piedmont "A. Avogadro", Novara, Italy
| | - Francesco Di Stanislao
- Department of Hygiene and Public Health, University "Politecnica delle Marche", Ancona, Italy
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Teasell RW, Foley NC, Salter KL, Jutai JW. A Blueprint for Transforming Stroke Rehabilitation Care in Canada: The Case for Change. Arch Phys Med Rehabil 2008; 89:575-8. [DOI: 10.1016/j.apmr.2007.08.164] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Revised: 08/23/2007] [Accepted: 08/25/2007] [Indexed: 10/22/2022]
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Weimar C, Ringelstein EB, Diener HC. [Monitoring stroke units: management, outcome, efficiency]. DER NERVENARZT 2008; 78:957-66. [PMID: 17516043 DOI: 10.1007/s00115-007-2268-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Treatment of acute stroke in Germany has undergone major changes. To date almost half of all stroke patients there are admitted to one of 172 accredited monitoring stroke units, 80 of which were classified as inter-regional and 92 as regional. Following acute treatment, diagnostic/etiologic work-up and automated monitoring of vital functions are performed as well as adapted secondary prevention. Another important therapeutic goal includes early rehabilitation. International studies have established the superiority of stroke unit treatment over conventional care. Although the efficiency of monitoring stroke units in Germany was not shown in a randomized study, the prognostic benefit is hardly debated anymore. In 2006 a specific procedure standard (OPS) was introduced, increasing proceeds to compensate for the higher cost of monitoring and therapy but at the same time enforcing strict quality standards.
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Affiliation(s)
- C Weimar
- Klinik für Neurologie, Universität Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany.
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Abstract
Stroke, a disorder encompassing all cerebrovascular accidents, is a public health problem of immense proportions across the globe. Therapeutic efforts are directed at three aspects: prevention, acute treatment, and rehabilitation. Preventative measures, which in many instances mirror those for cardiovascular disease, can achieve the greatest public health impact. Measures that enhance the recovery of neurologic function and reduce neurologic disability after stroke can also affect a large population of handicapped stroke survivors. In the past 10 years, the greatest changes have occurred in the field of acute stroke treatment. Ultra-early-stage therapies with the potential to dramatically reverse severe neurologic deficits, or halt their progression, have caused a restructuring of the emergency care of neurologic patients. The parallels with the evolution of emergency treatment of acute coronary syndromes after 1970 are striking. This review focuses on aspects of stroke therapy that are either just entering, or soon to enter, current practice.
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Affiliation(s)
- Nijasri Suwanwela
- Stroke Service, Chulalongkorn University Hospital, Bangkok, Thailand
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Chiu A, Shen Q, Cheuk G, Cordato D, Chan DKY. Establishment of a stroke unit in a district hospital: review of experience. Intern Med J 2007; 37:73-8. [PMID: 17229248 DOI: 10.1111/j.1445-5994.2007.01235.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The experience and outcomes of co-locating acute stroke and stroke rehabilitation care in a district hospital were reviewed. METHOD Information for patients admitted to Blacktown and Mt Druitt Hospitals before and after setting up an acute stroke unit (SU) (12 months data for each period), including mortality and length of stay (LOS) at the hospital were obtained from various sources, including the diagnosis-related group and subacute and non-acute casemix databases. RESULTS There was a significant reduction of mortality (18 vs 10%; P = 0.01) and reduced total LOS (46 vs 39 days; P = 0.01) with similar functional outcomes in the post-SU period. Fifty per cent of patients were unable to access the acute SU. Patients admitted into the SU had lower mortality (5 vs 14%; P = 0.01) and were also discharged from hospital earlier (35 vs 54 days; P = 0.01) than patients admitted into general wards during the post-SU period. Thirty-four per cent of patients received rehabilitation within the rehabilitation facility in the post-SU period compared with 19% in the pre-SU period. CONCLUSION The Blacktown experience showed the feasibility of establishing a co-located SU within rehabilitation facility with good outcomes as illustrated by the significant reduction in the stroke mortality, a reduction in the total LOS and an increase in the number of patients receiving rehabilitation post-stroke.
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Affiliation(s)
- A Chiu
- Geriatrics, Westmead Hospital, NSW, Australia
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Anis AH, Sun H, Singh S, Woolcott J, Nosyk B, Brisson M. A cost-utility analysis of losartan versus atenolol in the treatment of hypertension with left ventricular hypertrophy. PHARMACOECONOMICS 2006; 24:387-400. [PMID: 16605284 DOI: 10.2165/00019053-200624040-00008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
INTRODUCTION The LIFE (Losartan Intervention For Endpoint reduction in hypertension) study demonstrated a 13% relative risk reduction in the primary composite endpoint (myocardial infarction, stroke or death) for patients with hypertension and electrocardiographically diagnosed left ventricular hypertrophy (LVH) treated with losartan compared with atenolol. Losartan recipients also had a 25% relative risk reduction for stroke compared with atenolol recipients. Incorporating the results found in the LIFE study into an economic model, an incremental cost-effectiveness analysis was performed comparing losartan with atenolol in the treatment of 67-year old patients with hypertension and LVH. METHODS A Markov state transition model, based on published results of the LIFE trial (mean follow-up of 4.8 years), was utilised to extrapolate the outcomes observed in this trial to the patients' lifetime. Utility estimates for the associated health states were obtained from various published sources. Lifetime treatment costs were calculated adopting a societal perspective. Both costs and benefits were discounted and incremental cost-effectiveness ratios (ICERs) were estimated. One-way and probabilistic sensitivity analyses were performed. RESULTS The estimated ICER for losartan versus atenolol was 1337 Canadian dollars per QALY gained (1 Canadian dollar =0.75 US dollars, 2002 values). This ICER was robust to extensive sensitivity analysis, demonstrating a 95% probability that the ICER would be <20,000 Canadian dollars per QALY gained. CONCLUSION From a Canadian societal perspective, losartan appears to be a cost-effective alternative to atenolol in patients with hypertension and LVH. The estimated ICERs, including the sensitivity analyses, were within the range of cost-effectiveness ratios for various currently funded interventions and drugs in developed countries.
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Affiliation(s)
- Aslam H Anis
- Department of Health Care and Epidemiology, University of British Columbia, Vancouver, British Columbia, Canada.
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