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Falkenbach P, Raudasoja AJ, Vernooij RWM, Mustonen JMJ, Agarwal A, Aoki Y, Blanker MH, Cartwright R, Garcia-Perdomo HA, Kilpeläinen TP, Lainiala O, Lamberg T, Nevalainen OPO, Raittio E, Richard PO, Violette PD, Tikkinen KAO, Sipilä R, Turpeinen M, Komulainen J. Reporting of costs and economic impacts in randomized trials of de-implementation interventions for low-value care: a systematic scoping review. Implement Sci 2023; 18:36. [PMID: 37605243 PMCID: PMC10440866 DOI: 10.1186/s13012-023-01290-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/31/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND De-implementation of low-value care can increase health care sustainability. We evaluated the reporting of direct costs of de-implementation and subsequent change (increase or decrease) in health care costs in randomized trials of de-implementation research. METHODS We searched MEDLINE and Scopus databases without any language restrictions up to May 2021. We conducted study screening and data extraction independently and in duplicate. We extracted information related to study characteristics, types and characteristics of interventions, de-implementation costs, and impacts on health care costs. We assessed risk of bias using a modified Cochrane risk-of-bias tool. RESULTS We screened 10,733 articles, with 227 studies meeting the inclusion criteria, of which 50 included information on direct cost of de-implementation or impact of de-implementation on health care costs. Studies were mostly conducted in North America (36%) or Europe (32%) and in the primary care context (70%). The most common practice of interest was reduction in the use of antibiotics or other medications (74%). Most studies used education strategies (meetings, materials) (64%). Studies used either a single strategy (52%) or were multifaceted (48%). Of the 227 eligible studies, 18 (8%) reported on direct costs of the used de-implementation strategy; of which, 13 reported total costs, and 12 reported per unit costs (7 reported both). The costs of de-implementation strategies varied considerably. Of the 227 eligible studies, 43 (19%) reported on impact of de-implementation on health care costs. Health care costs decreased in 27 studies (63%), increased in 2 (5%), and were unchanged in 14 (33%). CONCLUSION De-implementation randomized controlled trials typically did not report direct costs of the de-implementation strategies (92%) or the impacts of de-implementation on health care costs (81%). Lack of cost information may limit the value of de-implementation trials to decision-makers. TRIAL REGISTRATION OSF (Open Science Framework): https://osf.io/ueq32 .
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Affiliation(s)
- Petra Falkenbach
- Finnish Coordinating Center for Health Technology Assessment, Oulu University Hospital, University of Oulu, Oulu, Finland.
| | - Aleksi J Raudasoja
- Finnish Medical Society Duodecim, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Robin W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Arnav Agarwal
- Department of Medicine, Division of General Internal Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Yoshitaka Aoki
- Department of Urology, University of Fukui Faculty of Medical Sciences, Fukui, Japan
| | - Marco H Blanker
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Rufus Cartwright
- Department of Gynaecology, Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Herney A Garcia-Perdomo
- Department of Surgery, Division of Urology/Uro-Oncology, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Tuomas P Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Olli Lainiala
- Department of Radiology, Faculty of Medicine and Health Technologies, Imaging Centre, Tampere University Hospital, Tampere University, Tampere, Finland
| | | | - Olli P O Nevalainen
- Wellbeing Services County of Pirkanmaa, Unit of Health Sciences, Faculty of Social Sciences, Hatanpää Health Center, Tampere University, Tampere, Finland
| | - Eero Raittio
- Department of Dentistry and Oral Health, Oral Health Care, Institute of Dentistry, Aarhus University, University of Eastern, Kuopio, Finland
| | - Patrick O Richard
- Division of Urology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Philippe D Violette
- Departments of Surgery and Health Research Methods Evidence and Impact, McMaster University, Hamilton, Canada
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
| | - Raija Sipilä
- Finnish Medical Society Duodecim, Helsinki, Finland
| | - Miia Turpeinen
- Oulu University Hospital, University of Oulu, Oulu, Finland
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Nevalainen OPO, Horstia S, Laakkonen S, Rutanen J, Mustonen JMJ, Kalliala IEJ, Ansakorpi H, Kreivi HR, Kuutti P, Paajanen J, Parkkila S, Paukkeri EL, Perola M, Pourjamal N, Renner A, Rosberg T, Rutanen T, Savolainen J, Haukka JK, Guyatt GH, Tikkinen KAO. Effect of remdesivir post hospitalization for COVID-19 infection from the randomized SOLIDARITY Finland trial. Nat Commun 2022; 13:6152. [PMID: 36257950 PMCID: PMC9579198 DOI: 10.1038/s41467-022-33825-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/04/2022] [Indexed: 12/24/2022] Open
Abstract
We report the first long-term follow-up of a randomized trial (NCT04978259) addressing the effects of remdesivir on recovery (primary outcome) and other patient-important outcomes one year after hospitalization resulting from COVID-19. Of the 208 patients recruited from 11 Finnish hospitals, 198 survived, of whom 181 (92%) completed follow-up. At one year, self-reported recovery occurred in 85% in remdesivir and 86% in standard of care (SoC) (RR 0.94, 95% CI 0.47-1.90). We infer no convincing difference between remdesivir and SoC in quality of life or symptom outcomes (p > 0.05). Of the 21 potential long-COVID symptoms, patients reported moderate/major bother from fatigue (26%), joint pain (22%), and problems with memory (19%) and attention/concentration (18%). In conclusion, after a one-year follow-up of hospitalized patients, one in six reported they had not recovered well from COVID-19. Our results provide no convincing evidence of remdesivir benefit, but wide confidence intervals included possible benefit and harm.
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Affiliation(s)
- Olli P. O. Nevalainen
- grid.7737.40000 0004 0410 2071Faculty of Medicine, University of Helsinki, Helsinki, Finland ,grid.502801.e0000 0001 2314 6254Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland ,Hatanpää Health Center, City of Tampere, Tampere, Finland ,grid.415018.90000 0004 0472 1956Pirkanmaa Hospital District, Tampere, Finland
| | - Saana Horstia
- grid.7737.40000 0004 0410 2071Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Sanna Laakkonen
- grid.7737.40000 0004 0410 2071Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jarno Rutanen
- grid.502801.e0000 0001 2314 6254Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland ,grid.412330.70000 0004 0628 2985Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | | | - Ilkka E. J. Kalliala
- grid.15485.3d0000 0000 9950 5666Department of Obstetrics and Gynaecology, Helsinki University and University Hospital Helsinki, Helsinki, Finland ,grid.7445.20000 0001 2113 8111Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Hanna Ansakorpi
- grid.10858.340000 0001 0941 4873Research Unit of Clinical Neuroscience, Neurology, University of Oulu, Oulu, Finland
| | - Hanna-Riikka Kreivi
- grid.7737.40000 0004 0410 2071Department of Pulmonology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pauliina Kuutti
- grid.7737.40000 0004 0410 2071Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Juuso Paajanen
- grid.7737.40000 0004 0410 2071Department of Pulmonology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Seppo Parkkila
- grid.412330.70000 0004 0628 2985Faculty of Medicine and Health Technology, Tampere University and Fimlab Ltd., Tampere University Hospital, Tampere, Finland
| | - Erja-Leena Paukkeri
- grid.412330.70000 0004 0628 2985Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Markus Perola
- grid.14758.3f0000 0001 1013 0499Department of Public Health and Welfare, Population Health Unit, Public Health Research Team, Finnish Institute for Health and Welfare, Helsinki, Finland ,grid.7737.40000 0004 0410 2071Clinical and Molecular Metabolism Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Negar Pourjamal
- grid.7737.40000 0004 0410 2071Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Andreas Renner
- grid.7737.40000 0004 0410 2071Department of Pulmonology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland ,grid.7737.40000 0004 0410 2071Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Tuomas Rosberg
- grid.413739.b0000 0004 0628 3152Department of Pulmonology, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | | | | | | | - Jari K. Haukka
- grid.502801.e0000 0001 2314 6254Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland ,grid.7737.40000 0004 0410 2071Clinicum/Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Gordon H. Guyatt
- grid.25073.330000 0004 1936 8227Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON Canada ,grid.25073.330000 0004 1936 8227Department of Medicine, McMaster University, Hamilton, ON Canada
| | - Kari A. O. Tikkinen
- grid.7737.40000 0004 0410 2071Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland ,Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
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Raudasoja AJ, Falkenbach P, Vernooij RWM, Mustonen JMJ, Agarwal A, Aoki Y, Blanker MH, Cartwright R, Garcia-Perdomo HA, Kilpeläinen TP, Lainiala O, Lamberg T, Nevalainen OPO, Raittio E, Richard PO, Violette PD, Komulainen J, Sipilä R, Tikkinen KAO. Randomized controlled trials in de-implementation research: a systematic scoping review. Implement Sci 2022; 17:65. [PMID: 36183140 PMCID: PMC9526943 DOI: 10.1186/s13012-022-01238-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Healthcare costs are rising, and a substantial proportion of medical care is of little value. De-implementation of low-value practices is important for improving overall health outcomes and reducing costs. We aimed to identify and synthesize randomized controlled trials (RCTs) on de-implementation interventions and to provide guidance to improve future research. METHODS MEDLINE and Scopus up to May 24, 2021, for individual and cluster RCTs comparing de-implementation interventions to usual care, another intervention, or placebo. We applied independent duplicate assessment of eligibility, study characteristics, outcomes, intervention categories, implementation theories, and risk of bias. RESULTS Of the 227 eligible trials, 145 (64%) were cluster randomized trials (median 24 clusters; median follow-up time 305 days), and 82 (36%) were individually randomized trials (median follow-up time 274 days). Of the trials, 118 (52%) were published after 2010, 149 (66%) were conducted in a primary care setting, 163 (72%) aimed to reduce the use of drug treatment, 194 (85%) measured the total volume of care, and 64 (28%) low-value care use as outcomes. Of the trials, 48 (21%) described a theoretical basis for the intervention, and 40 (18%) had the study tailored by context-specific factors. Of the de-implementation interventions, 193 (85%) were targeted at physicians, 115 (51%) tested educational sessions, and 152 (67%) multicomponent interventions. Missing data led to high risk of bias in 137 (60%) trials, followed by baseline imbalances in 99 (44%), and deficiencies in allocation concealment in 56 (25%). CONCLUSIONS De-implementation trials were mainly conducted in primary care and typically aimed to reduce low-value drug treatments. Limitations of current de-implementation research may have led to unreliable effect estimates and decreased clinical applicability of studied de-implementation strategies. We identified potential research gaps, including de-implementation in secondary and tertiary care settings, and interventions targeted at other than physicians. Future trials could be improved by favoring simpler intervention designs, better control of potential confounders, larger number of clusters in cluster trials, considering context-specific factors when planning the intervention (tailoring), and using a theoretical basis in intervention design. REGISTRATION OSF Open Science Framework hk4b2.
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Affiliation(s)
- Aleksi J Raudasoja
- Faculty of Medicine, University of Helsinki, Helsinki, Finland. .,Finnish Medical Society Duodecim, Helsinki, Finland.
| | - Petra Falkenbach
- Finnish Coordinating Center for Health Technology Assessment, Oulu University Hospital, Oulu, Finland.,University of Oulu, Oulu, Finland
| | - Robin W M Vernooij
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Arnav Agarwal
- Division of General Internal Medicine, Department of Medicine and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Yoshitaka Aoki
- Department of Urology, University of Fukui Faculty of Medical Sciences, Fukui, Japan
| | - Marco H Blanker
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Rufus Cartwright
- Department of Gynaecology, Chelsea & Westminster NHS Foundation Trust, London, UK.,Department of Epidemiology & Biostatistics, Imperial College London, London, UK
| | - Herney A Garcia-Perdomo
- Division of Urology/Uro-oncology, Department of Surgery, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Tuomas P Kilpeläinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Olli Lainiala
- Department of Radiology, Tampere University Hospital and Faculty of Medicine and Health Technologies, Tampere University, Tampere, Finland
| | | | - Olli P O Nevalainen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Hatanpää Health Center, City of Tampere, Finland.,Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Eero Raittio
- Oral Health Care, Tampere, Finland.,Institute of Dentistry, University of Eastern Finland, Kuopio, Finland.,Nordic Healthcare Group Ltd., Helsinki, Finland
| | - Patrick O Richard
- Division of Urology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Philippe D Violette
- Departments of Surgery and Health Research Methods Evidence and Impact, McMaster University, Hamilton, Canada
| | | | - Raija Sipilä
- Finnish Medical Society Duodecim, Helsinki, Finland
| | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
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