A framework for local-level economic evaluation to inform implementation decisions: health service interventions to prevent hospital-acquired hypoglycemia

OBJECTIVES

Published evidence on health service interventions should inform decision-making in local health services, but primary effectiveness studies and cost-effectiveness analyses are unlikely to reflect contexts other than those in which the evaluations were undertaken. A ten-step framework was developed and applied to use published evidence as the basis for local-level economic evaluations that estimate the expected costs and effects of new service intervention options in specific local contexts.

METHODS

Working with a multidisciplinary group of local clinicians, the framework was applied to evaluate intervention options for preventing hospital-acquired hypoglycemia. The framework included: clinical audit and analyses of local health systems data to understand the local context and estimate baseline event rates; pragmatic literature review to identify evidence on relevant intervention options; expert elicitation to adjust published intervention effect estimates to reflect the local context; and modeling to synthesize and calibrate data derived from the disparate data sources.

RESULTS

From forty-seven studies identified in the literature review, the working group selected three interventions for evaluation. The local-level economic evaluation generated estimates of intervention costs and a range of cost, capacity and patient outcome-related consequences, which informed working group recommendations to implement two of the interventions.

CONCLUSIONS

The applied framework for modeled local-level economic evaluation was valued by local stakeholders, in particular the structured, formal approach to identifying and interpreting published evidence alongside local data. Key methodological issues included the handling of alternative reported outcomes and the elicitation of the expected intervention effects in the local context.

Intrahepatic cholestasis of pregnancy - Diagnosis and management: A consensus statement of the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ): Executive summary

Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy liver disease, characterised by pruritus and increased total serum bile acids (TSBA), Australian incidence 0.6-0.7%. ICP is diagnosed by non-fasting TSBA ≥19 μmol/L in a pregnant woman with pruritus without rash without a known pre-existing liver disorder. Peak TSBA ≥40 and ≥100 μmol/L identify severe and very severe disease respectively, associated with spontaneous preterm birth when severe, and with stillbirth, when very severe. Benefit-vs-risk for iatrogenic preterm birth in ICP remains uncertain. Ursodeoxycholic acid remains the best pharmacotherapy preterm, improving perinatal outcome and reducing pruritus, although it has not been shown to reduce stillbirth.

Antibiotic resistance of Helicobacter pylori in Australia and New Zealand: A systematic review and meta-analysis

OBJECTIVE

While the global prevalence of antibiotic-resistant Helicobacter pylori (H. pylori) is increasing, there is much regional variation, and local data are required to guide eradication therapy. We performed a systematic review and meta-analysis to determine rates of H. pylori antibiotic resistance in Australia and New Zealand.

STUDY DESIGN

Random effects meta-analysis of data from 15 published studies and three published abstracts reporting prevalence of primary or secondary H. pylori antibiotic resistance in Australasia.

DATA SOURCES

PubMed, EMBASE, MEDLINE, PROSPERO, and the Cochrane Library were searched until August, 2020.

DATA SYNTHESIS

Fifteen published studies and three published abstracts were identified; one study was excluded due to high risk of bias. Seventeen studies conducted between 1996 and 2013 were included in the final analysis, 12 reporting primary and five reporting secondary antibiotic resistance. Prevalence of primary resistance was clarithromycin 7.4% (95% confidence interval [CI], 5.3-9.7%), metronidazole 50.0% (95%CI, 23.9-56.1%), fluoroquinolones 3.7% (95%CI, 0.004-14.8%), and both amoxicillin and tetracycline <0.5%. Subgroup analysis (last 20 years) showed doubling of clarithromycin resistance to 16.1% (95%CI 11.2-21.7%) with other resistance stable. Prevalence of secondary resistance was high for all antibiotics, particularly clarithromycin 78.7% (95%CI, 64.1-90.1%) and metronidazole 68.3% (95%CI, 59.9-76.1%).

CONCLUSIONS

The outcomes reveal an increase in primary H. pylori clarithromycin resistance since the year 2000, while metronidazole resistance has remained stable and primary resistance to amoxicillin, tetracycline, and fluoroquinolones is low. Rates of secondary resistance to metronidazole and clarithromycin are high. The results highlight the need for contemporary local data on antibiotic resistance in Australia and New Zealand.

Eplerenone as a treatment for resistant hypertension in pregnancy

Mineralocorticoid receptor antagonists are highly effective in the management of resistant hypertension and primary hyperaldosteronism. Recent studies demonstrate that mineralocorticoid receptor antagonists significantly reduce blood pressure, severity of obstructive sleep apnoea and arterial stiffness in patients with resistant hypertension and moderate-severe obstructive sleep apnoea. Eplerenone is a selective mineralocorticoid receptor antagonist that does not act as an androgen receptor blocker, thus reducing the risk of fetal anti-androgenic effects. Rat and rabbit studies demonstrated that when exposed to 30 times the equivalent therapeutic human dose, 100 mg/day, there were no teratogenic or demasculinisation effects. To date, the use of eplerenone has been reported in six human pregnancies in women with Gitelman syndrome, primary hyperaldosteronism and cardiac failure, in which no teratogenic effects were seen. Described here is a case of resistant hypertension associated with obstructive sleep apnoea in pregnancy, treated with eplerenone. The potential role of using eplerenone in pregnancy as treatment for resistant hypertension is discussed. Trial registration: Not applicable.

Hypercalcaemia during pregnancy: Review of maternal and fetal complications, investigations, and management

Introduction

Asymptomatic mild primary hyperparathyroidism is increasingly being identified during pregnancy. Recent studies have demonstrated inconsistent findings with regard to pregnancy complications and the need for surgical intervention during pregnancy.

Method

A retrospective audit of outcomes of pregnancies complicated by hypercalcaemia over a 15-year period was performed.

Results

Twenty-nine pregnancies to 26 women with hypercalcaemia were identified, corresponding to 37 cases per 100,000 deliveries. Hypercalcaemia was due to primary hyperparathyroidism in 90% of cases, with mean serum calcium of 2.89 mmol/l and mean ionised calcium 1.43 mmol/l. Four women underwent successful neck exploration during pregnancy. Pregnancy complications were limited to three cases of pre-eclampsia and one case of symptomatic neonatal hypoparathyroidism.

Conclusion

Close observation without surgical intervention would seem reasonable in women with mild hypercalcaemia during pregnancy.

[Community analysis serving as a foundation for community-based health promotion programming--results of a citizen survey in Karlshuld, Germany]

BACKGROUND

Analysing a community's needs and requirements is useful for planning a community-based health promotion programme. The literature recommends the analysis of existing population-based data, the discussion with a community's key persons, and standardised surveys among the community members. With regagrd to the latter method, German-language literature is scarce.

AIM

A community analysis in the Bavarian rural community Karlshuld (5 000 inhabitants) was intended to provide a starting point for tailored health promotion activities in the community. As a part of the community analysis, a survey among the Karlshuld citizens was intended to inform about (1) health-related knowledge and behaviour of the community members, (2) their utilization and acceptance of existing health-related offers and activities, (3) their possibilities for active participation, their state of empowerment and (4) community-related aspects influencing quality of life.

METHODS

A standardised telephone survey was performed with a random sample of Karlshuld community members aged 15 years and older. The questions covered health-related living conditions and activities in Karlshuld, quality of life and participation of community members. In addition, data were collected on knowledge, attitude and behaviour with regard to the issues nutrition, physical activity and tobacco consumption. The sample comprised 314 community members (f=68.8%; age 43.9+/-13.8 years).

RESULTS

Shortcomings in knowledge on healthy nutrition were evident, especially among male participants. Whereas the general attitude towards a healthy diet was favourable in the majority of respondents, only 45.9%/58.6% stated that they daily consumed vegetables/fruit. One third of the 27.4% smokers among the respondents had intended but failed to quit smoking in the previous year; 80% stated they were willing to quit. The participants named infrastructure, nature and health-related activities as positive aspects in Karlshuld. Only 50% knew where to get information on health-related issues. 42.9% of respondents felt they could influence decisions on health-related issues in the community. There was no correlation between school education and knowledge or participation.

DISCUSSION

The survey among Karlshuld community members identified potential approaches to improving the community environment and to tailor health education activities to the special needs of Karlshuld. A follow-up survey in 2008/2009 will be carried out in order to evaluate whether or not the Karlshuld health promotion programme was successful in building on Karlshuld's strengths and influencing its weaknesses.

[Community-based health promotion--a challenge for the evaluation]

PURPOSE

Community-based health promotion (CBHP) aims at mobilising citizens for health-related issues in their environment, and at implementing health-promoting projects on the community level. Whereas recent political decisions support this approach, scientific studies dealing with theories and consequences of CBHP are scarce in Germany. Evaluation of CBHP could help identify (in)effective factors and elements of community programmes and thus improve future planning. In Germany, however, there is a deficit in systematic concepts and recommendations for the evaluation of CBHP. This work outlines basic ideas and core principles of CBHP and deduces implications for the assessment of health-promoting community projects.

METHODS

Based on different international models and studies and on discussions with health promotion professionals, we developed a framework for the evaluation of CBHP.

RESULTS

The proposed framework includes a guideline for CBHP programme planning. Its strategic and operational criteria can serve as a basis for a strategy evaluation. In terms of process evaluation, indicators for the dimensions (1) programme implementation and service delivery, (2) capacity building, and (3) reach of and acceptability in the target group were developed. In addition, we present different areas of OUTCOME EVALUATION; it is advisable to distinguish between measurement on the individual and on the community level. The framework further proposes strategies for the evaluation of the core principles empowerment and participation.

CONCLUSION

The presented framework can serve as a basis for the development of flexible and individual instruments for the evaluation of CBHP, which should not ignore the perspective of the citizens, or complex aspects like changes on the community level. Some aspects, e.g., the potential evaluation of further targets of CBHP (improvement of quality of life, reduction of social and health inequalities), the responsibility of evaluation or the effects of financial constraints, are important questions to be addressed in the future.