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Taylor NL, Porter JM, Bryan S, Harmon KJ, Sandt LS. Structural Racism and Pedestrian Safety: Measuring the Association Between Historical Redlining and Contemporary Pedestrian Fatalities Across the United States, 2010‒2019. Am J Public Health 2023; 113:420-428. [PMID: 36888942 PMCID: PMC10003496 DOI: 10.2105/ajph.2022.307192] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 03/10/2023]
Abstract
Objectives. To examine the association between historical redlining and contemporary pedestrian fatalities across the United States. Methods. We analyzed 2010-2019 traffic fatality data, obtained from the Fatality Analysis Reporting System, for all US pedestrian fatalities linked by location of crash to 1930s Home Owners' Loan Corporation (HOLC) grades and current sociodemographic factors at the census tract level. We applied generalized estimating equation models to assess the relationship between the count of pedestrian fatalities and redlining. Results. In an adjusted multivariable analysis, tracts graded D ("Hazardous") had a 2.60 (95% confidence interval = 2.26, 2.99) incidence rate ratio (per residential population) of pedestrian fatalities compared with tracts graded A ("Best"). We found a significant dose‒response relationship: as grades worsened from A to D, rates of pedestrian fatalities increased. Conclusions. Historical redlining policy, initiated in the 1930s, has an impact on present-day transportation inequities in the United States. Public Health Implications. To reduce transportation inequities, understanding how structurally racist policies, past and present, have an impact on community-level investments in transportation and health is crucial. (Am J Public Health. 2023;113(4):420-428. https://doi.org/10.2105/AJPH.2022.307192).
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Affiliation(s)
- Nandi L Taylor
- Nandi L. Taylor is with the Injury Prevention Research Center and Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Jamila M. Porter is with the Office of the CEO, de Beaumont Foundation, Bethesda, MD. Shenee Bryan is with S. Bryan Consulting LLC, Atlanta, GA. Katherine J. Harmon is with Injury Prevention Research Center and Highway Safety Research Center, University of North Carolina at Chapel Hill. Laura S. Sandt is with the Highway Safety Research Center, University of North Carolina at Chapel Hill
| | - Jamila M Porter
- Nandi L. Taylor is with the Injury Prevention Research Center and Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Jamila M. Porter is with the Office of the CEO, de Beaumont Foundation, Bethesda, MD. Shenee Bryan is with S. Bryan Consulting LLC, Atlanta, GA. Katherine J. Harmon is with Injury Prevention Research Center and Highway Safety Research Center, University of North Carolina at Chapel Hill. Laura S. Sandt is with the Highway Safety Research Center, University of North Carolina at Chapel Hill
| | - Shenee Bryan
- Nandi L. Taylor is with the Injury Prevention Research Center and Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Jamila M. Porter is with the Office of the CEO, de Beaumont Foundation, Bethesda, MD. Shenee Bryan is with S. Bryan Consulting LLC, Atlanta, GA. Katherine J. Harmon is with Injury Prevention Research Center and Highway Safety Research Center, University of North Carolina at Chapel Hill. Laura S. Sandt is with the Highway Safety Research Center, University of North Carolina at Chapel Hill
| | - Katherine J Harmon
- Nandi L. Taylor is with the Injury Prevention Research Center and Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Jamila M. Porter is with the Office of the CEO, de Beaumont Foundation, Bethesda, MD. Shenee Bryan is with S. Bryan Consulting LLC, Atlanta, GA. Katherine J. Harmon is with Injury Prevention Research Center and Highway Safety Research Center, University of North Carolina at Chapel Hill. Laura S. Sandt is with the Highway Safety Research Center, University of North Carolina at Chapel Hill
| | - Laura S Sandt
- Nandi L. Taylor is with the Injury Prevention Research Center and Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Jamila M. Porter is with the Office of the CEO, de Beaumont Foundation, Bethesda, MD. Shenee Bryan is with S. Bryan Consulting LLC, Atlanta, GA. Katherine J. Harmon is with Injury Prevention Research Center and Highway Safety Research Center, University of North Carolina at Chapel Hill. Laura S. Sandt is with the Highway Safety Research Center, University of North Carolina at Chapel Hill
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Nesbit B, Robinson I, Bryan S. A national landscape: Injury and violence prevention health equity scan findings and implications for the field of practice. J Safety Res 2022; 80:457-462. [PMID: 35249626 PMCID: PMC9885368 DOI: 10.1016/j.jsr.2021.12.026] [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] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/20/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Many federal and national partners have a renewed commitment to addressing health equity and racial equity as a public health issue of concern. These are especially important issues in addressing many injury and violence prevention (IVP) topic areas. In developing and updating approaches to address injury and violence-related health and racial equity challenges, CDC and Safe States Alliance wanted to better understand how partners in the field are already approaching these issues. An environmental scan was conducted to explore how IVP professionals advance health equity and racial equity in their programmatic work. METHODS Data collection occurred from multiple sources including focus groups and surveys. Health equity and racial equity-related questions were added to the Safe States Member Survey: Evaluating the Impact of COVID-19 on the IVP Workforce and Assessing Equity Initiative (COVID Impact and Equity Survey). An analysis of secondary data sources was conducted through ongoing evaluation initiatives at Safe States Alliance (the COVID Impact Evaluation and Connections Lab Evaluation Focus Groups). CONCLUSIONS Successes and challenges were identified through the environmental scan that primarily fell into three categories: (1) Injury and Violence Prevention Strategies and Programs, (2) Using IVP Data to Inform Equity Approaches, (3) Equity Approaches in IVP Infrastructure. Practical Applications: Practical applications were identified that can be supported at the local, state, and federal/national level and are specific to the areas of IVP strategies and programs, IVP data and surveillance, and IVP organizational infrastructure. A few examples include: (1) Ensuring decision-making power and ownership of programs is shared between community partners and funders; (2) Working with national/federal surveillance system partners to ensure demographic fields/variables are improved to identify disparities and inequities; (3) Development of an "Injury and Violence Prevention Equity Institute" to better prepare IVP professionals to address health and racial equity challenges.
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Affiliation(s)
- Brandon Nesbit
- National Center for Injury Prevention and Control (NCIPC), Centers for Disease Control and Prevention (CDC), USA.
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Sherwood K, Tran J, Günther O, Lan J, Aiyegbusi O, Liwski R, Sapir-Pichhadze R, Bryan S, Caulfield T, Keown P. Genome Canada precision medicine strategy for structured national implementation of epitope matching in renal transplantation. Hum Immunol 2022; 83:264-269. [DOI: 10.1016/j.humimm.2022.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/12/2021] [Accepted: 01/05/2022] [Indexed: 02/08/2023]
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McNally M, Rock L, Gillis M, Bryan S, Boyd C, Kraglund F, Cleghorn B. Reopening Oral Health Services during the COVID-19 Pandemic through a Knowledge Exchange Coalition. JDR Clin Trans Res 2021; 6:279-290. [PMID: 33902341 PMCID: PMC8207488 DOI: 10.1177/23800844211011985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The COVID-19 novel coronavirus closed oral health care in Nova Scotia (NS) Canada in March 2020. Preparing for a phased reopening, a knowledge exchange coalition (representing government, academia, hospitals, oral health professions, and regulators) developed return-to-work (RTW) guidelines detailing the augmentation of standard practices to ensure safety for patients, oral health care providers (OHPs), and the community. Using online surveys, this study explored the influence of the RTW guidelines and related education on registered NS OHPs during a phased return to work. METHODS Dissemination of R2W guidelines included website or email communiques and interdisciplinary education webinars that coincided with 2 RTW phases approved by the government. Aligned with each phase, all registered dentists, dental hygienists, and dental assistants were invited to complete an online survey to gauge the influence of the coalition-sponsored education and RTW guidelines, confidence, preparedness, and personal protective equipment use before and after the pandemic. RESULTS Three coalition-sponsored multidisciplinary webinars hosted 3541 attendees prior to RTW. The response to survey 1 was 41% (881/2156) and to survey 2 was 26% (571/2177) of registrants. Survey 1 (82%) and survey 2 (89%) respondents "agreed/strongly agreed" that R2W guidelines were a primary source for guiding return to practice, and most were confident with education received and had the skills needed to effectively treat patients during the COVID-19 pandemic. Confidence and preparedness improved in survey 2. Gowns/lab coat use for aerosol-generating procedures increased from 26% to 93%, and the use of full face shields rose from 6% to 93% during the pandemic. CONCLUSIONS A multistakeholder coalition was effective in establishing and communicating comprehensive guidelines and web-based education to ensure unified reintegration of oral health services in NS during a pandemic. This multiorganizational cooperation lay the foundation for responses to subsequent waves of COVID-19 and may serve as an example for collaboratively responding to future public health threats in other settings. KNOWLEDGE TRANSFER STATEMENT The return-to-work strategy that was developed, disseminated, and assessed through this COVID-19 knowledge exchange coalition will benefit oral health practitioners, professional regulators, government policy makers, and researchers in future pandemic planning.
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Affiliation(s)
- M McNally
- Faculty of Dentistry, Dalhousie University, Halifax, NS, Canada
| | - L Rock
- School of Dental Hygiene, Dalhousie University, Halifax, NS, Canada
| | - M Gillis
- Provincial Dental Board of Nova Scotia, Bedford, NS, Canada
| | - S Bryan
- College of Dental Hygienists of Nova Scotia, Halifax, NS, Canada
| | - C Boyd
- Faculty of Dentistry, Dalhousie University, Halifax, NS, Canada
| | - F Kraglund
- Faculty of Dentistry, Dalhousie University, Halifax, NS, Canada
| | - B Cleghorn
- Faculty of Dentistry, Dalhousie University, Halifax, NS, Canada
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Lotti F, Twedt D, Warrit K, Bryan S, Vaca C, Krause L, Fukushima K, Boscan P. Effect of two different pre-anaesthetic omeprazole protocols on gastroesophageal reflux incidence and pH in dogs. J Small Anim Pract 2021; 62:677-682. [PMID: 33769569 DOI: 10.1111/jsap.13328] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 02/09/2021] [Accepted: 02/21/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Gastroesophageal reflux can occur during anaesthesia and may lead to esophagitis and occasionally oesophageal stricture formation. The aim of the study is to assess two omeprazole protocols on gastroesophageal reflux incidence and pH in anaesthetised dogs. MATERIALS AND METHODS Fifty-five dogs undergoing elective ovariectomy were randomly assigned to: omeprazole single dose 1 mg/kg orally the evening before anaesthesia (20 dogs), omeprazole two doses 1 mg/kg orally the evening and 3 hours before anaesthesia (15 dogs), and control group that did not receive omeprazole (20 dogs). An oesophageal impedance/pH probe was used to measure gastroesophageal reflux incidence and pH during anaesthesia. RESULTS Gastroesophageal reflux was observed in 55% (11/20) of control dogs, 55% (11/20) of dogs receiving omeprazole once and 47% (7/15) of dogs receiving omeprazole twice. The incidence was not statistically significant different between groups. Gastroesophageal reflux pH (mean ± sd) was higher in dogs receiving omeprazole twice (6.3 ± 1.5), when compared to either control dogs (3.8 ± 1.1) or dogs receiving omeprazole once (4.1 ± 1.5). Strongly acidic reflux (pH < 4) was observed in 7% (1/15) of dogs receiving omeprazole twice versus 55% (11/20) and 35% (7/20) of control dogs and dogs receiving omeprazole once, respectively. CLINICAL SIGNIFICANCE Omeprazole administered the evening and 3 hours before anaesthesia increased gastroesophageal reflux pH and decreased the incidence of strongly acidic reflux in dogs. A single dose of omeprazole given the evening before anaesthesia had no effect on reflux pH.
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Affiliation(s)
- F Lotti
- Department of Clinical Sciences, Veterinary Teaching Hospital (Colorado State University), 300 W. Drake, Fort Collins, CO, 80523-1678, USA
| | - D Twedt
- Department of Clinical Sciences, Veterinary Teaching Hospital (Colorado State University), 300 W. Drake, Fort Collins, CO, 80523-1678, USA
| | - K Warrit
- Department of Clinical Sciences, Veterinary Teaching Hospital (Colorado State University), 300 W. Drake, Fort Collins, CO, 80523-1678, USA
| | - S Bryan
- Department of Clinical Sciences, Veterinary Teaching Hospital (Colorado State University), 300 W. Drake, Fort Collins, CO, 80523-1678, USA
| | - C Vaca
- Department of Clinical Sciences, Veterinary Teaching Hospital (Colorado State University), 300 W. Drake, Fort Collins, CO, 80523-1678, USA
| | - L Krause
- Department of Clinical Sciences, Veterinary Teaching Hospital (Colorado State University), 300 W. Drake, Fort Collins, CO, 80523-1678, USA
| | - K Fukushima
- Department of Clinical Sciences, Veterinary Teaching Hospital (Colorado State University), 300 W. Drake, Fort Collins, CO, 80523-1678, USA
| | - P Boscan
- Department of Clinical Sciences, Veterinary Teaching Hospital (Colorado State University), 300 W. Drake, Fort Collins, CO, 80523-1678, USA
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Trenaman L, Stacey D, Bryan S, Payne K, Hawker G, Bansback N. Long-term effect of patient decision aids on use of joint replacement and health care costs. Osteoarthritis Cartilage 2020; 28:819-823. [PMID: 32173628 DOI: 10.1016/j.joca.2020.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/19/2019] [Accepted: 01/06/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Shared decision-making supported by patient decisions aids may improve care and reduce healthcare costs for persons considering total joint replacement. Observational studies and randomized controlled trials (RCTs) have evaluated the short-term impact of decision aids on uptake of surgery and costs, however the long-term effects are unclear. This analysis aimed to evaluate the effect of patient decision aids on 1) use of joint replacement up to 7-years of follow-up, and 2) osteoarthritis-related health system costs. METHODS 324 participants in a Canadian RCT with 2-years follow-up who were randomized to either a decision aid (n = 161) or usual care (n = 163) had their trial and health administrative data linked. The proportion undergoing surgery up to 7-years were compared using cumulative incidence plots and competing risk regression. Mean per-patient costs were compared using two sample t-tests. RESULTS At 2-years, 119 of 161 (73.9%) patients in the decision aid arm and 129 of 163 (79.1%) patients in the usual care arm had surgery. Between two and 7-years, 17 additional patients in both the decision aid (of 42, 40.4%) and usual care (of 34, 50.0%) arms underwent surgery. At 7-years, patients exposed to decision aids had a similar likelihood of undergoing surgery (HR = 0.92, 95% CI:0.73 to 1.17, p = 0.49) and mean per-patient costs ($21,965 vs $23,681, incremental cost: -$1,717, 95% CI:-$5,631 to $2,198) compared to those in usual care. CONCLUSIONS This is the first study to assess the long-term impact of decision aids on use of joint replacement and healthcare costs. These results are not conclusive but can inform future trial design. CLINICAL TRIAL REGISTRATION The full trial protocol is available at ClinicalTrials.Gov (NCT00911638).
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Affiliation(s)
- L Trenaman
- University of British Columbia, Vancouver, Canada; Centre for Health Evaluation and Outcome Sciences, Vancouver, Canada
| | - D Stacey
- University of Ottawa, Ottawa, Canada
| | - S Bryan
- University of British Columbia, Vancouver, Canada
| | - K Payne
- The University of Manchester, Manchester, UK
| | - G Hawker
- The University of Toronto, Toronto, Canada
| | - N Bansback
- University of British Columbia, Vancouver, Canada; Centre for Health Evaluation and Outcome Sciences, Vancouver, Canada.
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Ahmed S, Barbera L, Bartlett SJ, Bebb DG, Brundage M, Bryan S, Cheung WY, Coburn N, Crump T, Cuthbertson L, Howell D, Klassen AF, Leduc S, Li M, Mayo NE, McKinnon G, Olson R, Pink J, Robinson JW, Santana MJ, Sawatzky R, Moxam RS, Sinclair S, Servidio-Italiano F, Temple W. A catalyst for transforming health systems and person-centred care: Canadian national position statement on patient-reported outcomes. Curr Oncol 2020; 27:90-99. [PMID: 32489251 PMCID: PMC7253746 DOI: 10.3747/co.27.6399] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Patient-reported outcomes (pros) are essential to capture the patient's perspective and to influence care. Although pros and pro measures are known to have many important benefits, they are not consistently being used and there is there no Canadian pros oversight. The Position Statement presented here is the first step toward supporting the implementation of pros in the Canadian health care setting. Methods The Canadian pros National Steering Committee drafted position statements, which were submitted for stakeholder feedback before, during, and after the first National Canadian Patient Reported Outcomes (canpros) scientific conference, 14-15 November 2019 in Calgary, Alberta. In addition to the stakeholder feedback cycle, a patient advocate group submitted a section to capture the patient voice. Results The canpros Position Statement is an outcome of the 2019 canpros scientific conference, with an oncology focus. The Position Statement is categorized into 6 sections covering 4 theme areas: Patient and Families, Health Policy, Clinical Implementation, and Research. The patient voice perfectly mirrors the recommendations that the experts reached by consensus and provides an overriding impetus for the use of pros in health care. Conclusions Although our vision of pros transforming the health care system to be more patient-centred is still aspirational, the Position Statement presented here takes a first step toward providing recommendations in key areas to align Canadian efforts. The Position Statement is directed toward a health policy audience; future iterations will target other audiences, including researchers, clinicians, and patients. Our intent is that future versions will broaden the focus to include chronic diseases beyond cancer.
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Affiliation(s)
- S Ahmed
- Quebec: Department of Medicine School of Physical and Occupational Therapy, McGill University, Montreal (Ahmed, Mayo); Faculty of Medicine, McGill University, and McGill University Health Systems, Montreal (Bartlett)
| | - L Barbera
- Alberta: Department of Oncology, University of Calgary, Calgary (Barbera, Bebb, Cheung); University of Calgary, Calgary (Crump, Temple); Departments of Surgery and Oncology, University of Calgary, Calgary (McKinnon); Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary (Pink, Santana); University of Calgary and Tom Baker Cancer Centre, Calgary (Robinson); Faculty of Nursing, University of Calgary, Calgary (Sinclair)
| | - S J Bartlett
- Quebec: Department of Medicine School of Physical and Occupational Therapy, McGill University, Montreal (Ahmed, Mayo); Faculty of Medicine, McGill University, and McGill University Health Systems, Montreal (Bartlett)
| | - D G Bebb
- Alberta: Department of Oncology, University of Calgary, Calgary (Barbera, Bebb, Cheung); University of Calgary, Calgary (Crump, Temple); Departments of Surgery and Oncology, University of Calgary, Calgary (McKinnon); Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary (Pink, Santana); University of Calgary and Tom Baker Cancer Centre, Calgary (Robinson); Faculty of Nursing, University of Calgary, Calgary (Sinclair)
| | - M Brundage
- Ontario: Queen's Cancer Research Institute, Kingston (Brundage); Sunnybrook Health Sciences Centre, Toronto (Coburn); Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto (Howell); McMaster University, Hamilton (Klassen); CancerInsight, Oakville (Leduc); Department of Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Toronto (Li); Canadian Partnership Against Cancer, Toronto (Moxam); Colorectal Cancer Resource and Action Network, Oakville (Servidio-Italiano)
| | - S Bryan
- British Columbia: School of Population and Public Health, University of British Columbia, Vancouver (Bryan); Office of Patient-Centred Measurement, British Columbia Ministry of Health, Vancouver (Cuthbertson); Radiation Oncology and Developmental Radiotherapeutics, University of British Columbia, Prince George (Olson); School of Nursing, Trinity Western University, Langley (Sawatzky)
| | - W Y Cheung
- Alberta: Department of Oncology, University of Calgary, Calgary (Barbera, Bebb, Cheung); University of Calgary, Calgary (Crump, Temple); Departments of Surgery and Oncology, University of Calgary, Calgary (McKinnon); Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary (Pink, Santana); University of Calgary and Tom Baker Cancer Centre, Calgary (Robinson); Faculty of Nursing, University of Calgary, Calgary (Sinclair)
| | - N Coburn
- Ontario: Queen's Cancer Research Institute, Kingston (Brundage); Sunnybrook Health Sciences Centre, Toronto (Coburn); Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto (Howell); McMaster University, Hamilton (Klassen); CancerInsight, Oakville (Leduc); Department of Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Toronto (Li); Canadian Partnership Against Cancer, Toronto (Moxam); Colorectal Cancer Resource and Action Network, Oakville (Servidio-Italiano)
| | - T Crump
- Alberta: Department of Oncology, University of Calgary, Calgary (Barbera, Bebb, Cheung); University of Calgary, Calgary (Crump, Temple); Departments of Surgery and Oncology, University of Calgary, Calgary (McKinnon); Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary (Pink, Santana); University of Calgary and Tom Baker Cancer Centre, Calgary (Robinson); Faculty of Nursing, University of Calgary, Calgary (Sinclair)
| | - L Cuthbertson
- British Columbia: School of Population and Public Health, University of British Columbia, Vancouver (Bryan); Office of Patient-Centred Measurement, British Columbia Ministry of Health, Vancouver (Cuthbertson); Radiation Oncology and Developmental Radiotherapeutics, University of British Columbia, Prince George (Olson); School of Nursing, Trinity Western University, Langley (Sawatzky)
| | - D Howell
- Ontario: Queen's Cancer Research Institute, Kingston (Brundage); Sunnybrook Health Sciences Centre, Toronto (Coburn); Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto (Howell); McMaster University, Hamilton (Klassen); CancerInsight, Oakville (Leduc); Department of Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Toronto (Li); Canadian Partnership Against Cancer, Toronto (Moxam); Colorectal Cancer Resource and Action Network, Oakville (Servidio-Italiano)
| | - A F Klassen
- Ontario: Queen's Cancer Research Institute, Kingston (Brundage); Sunnybrook Health Sciences Centre, Toronto (Coburn); Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto (Howell); McMaster University, Hamilton (Klassen); CancerInsight, Oakville (Leduc); Department of Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Toronto (Li); Canadian Partnership Against Cancer, Toronto (Moxam); Colorectal Cancer Resource and Action Network, Oakville (Servidio-Italiano)
| | - S Leduc
- Ontario: Queen's Cancer Research Institute, Kingston (Brundage); Sunnybrook Health Sciences Centre, Toronto (Coburn); Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto (Howell); McMaster University, Hamilton (Klassen); CancerInsight, Oakville (Leduc); Department of Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Toronto (Li); Canadian Partnership Against Cancer, Toronto (Moxam); Colorectal Cancer Resource and Action Network, Oakville (Servidio-Italiano)
| | - M Li
- Ontario: Queen's Cancer Research Institute, Kingston (Brundage); Sunnybrook Health Sciences Centre, Toronto (Coburn); Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto (Howell); McMaster University, Hamilton (Klassen); CancerInsight, Oakville (Leduc); Department of Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Toronto (Li); Canadian Partnership Against Cancer, Toronto (Moxam); Colorectal Cancer Resource and Action Network, Oakville (Servidio-Italiano)
| | - N E Mayo
- Quebec: Department of Medicine School of Physical and Occupational Therapy, McGill University, Montreal (Ahmed, Mayo); Faculty of Medicine, McGill University, and McGill University Health Systems, Montreal (Bartlett)
| | - G McKinnon
- Alberta: Department of Oncology, University of Calgary, Calgary (Barbera, Bebb, Cheung); University of Calgary, Calgary (Crump, Temple); Departments of Surgery and Oncology, University of Calgary, Calgary (McKinnon); Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary (Pink, Santana); University of Calgary and Tom Baker Cancer Centre, Calgary (Robinson); Faculty of Nursing, University of Calgary, Calgary (Sinclair)
| | - R Olson
- British Columbia: School of Population and Public Health, University of British Columbia, Vancouver (Bryan); Office of Patient-Centred Measurement, British Columbia Ministry of Health, Vancouver (Cuthbertson); Radiation Oncology and Developmental Radiotherapeutics, University of British Columbia, Prince George (Olson); School of Nursing, Trinity Western University, Langley (Sawatzky)
| | - J Pink
- Alberta: Department of Oncology, University of Calgary, Calgary (Barbera, Bebb, Cheung); University of Calgary, Calgary (Crump, Temple); Departments of Surgery and Oncology, University of Calgary, Calgary (McKinnon); Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary (Pink, Santana); University of Calgary and Tom Baker Cancer Centre, Calgary (Robinson); Faculty of Nursing, University of Calgary, Calgary (Sinclair)
| | - J W Robinson
- Alberta: Department of Oncology, University of Calgary, Calgary (Barbera, Bebb, Cheung); University of Calgary, Calgary (Crump, Temple); Departments of Surgery and Oncology, University of Calgary, Calgary (McKinnon); Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary (Pink, Santana); University of Calgary and Tom Baker Cancer Centre, Calgary (Robinson); Faculty of Nursing, University of Calgary, Calgary (Sinclair)
| | - M J Santana
- Alberta: Department of Oncology, University of Calgary, Calgary (Barbera, Bebb, Cheung); University of Calgary, Calgary (Crump, Temple); Departments of Surgery and Oncology, University of Calgary, Calgary (McKinnon); Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary (Pink, Santana); University of Calgary and Tom Baker Cancer Centre, Calgary (Robinson); Faculty of Nursing, University of Calgary, Calgary (Sinclair)
| | - R Sawatzky
- British Columbia: School of Population and Public Health, University of British Columbia, Vancouver (Bryan); Office of Patient-Centred Measurement, British Columbia Ministry of Health, Vancouver (Cuthbertson); Radiation Oncology and Developmental Radiotherapeutics, University of British Columbia, Prince George (Olson); School of Nursing, Trinity Western University, Langley (Sawatzky)
| | - R S Moxam
- Ontario: Queen's Cancer Research Institute, Kingston (Brundage); Sunnybrook Health Sciences Centre, Toronto (Coburn); Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto (Howell); McMaster University, Hamilton (Klassen); CancerInsight, Oakville (Leduc); Department of Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Toronto (Li); Canadian Partnership Against Cancer, Toronto (Moxam); Colorectal Cancer Resource and Action Network, Oakville (Servidio-Italiano)
| | - S Sinclair
- Alberta: Department of Oncology, University of Calgary, Calgary (Barbera, Bebb, Cheung); University of Calgary, Calgary (Crump, Temple); Departments of Surgery and Oncology, University of Calgary, Calgary (McKinnon); Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary (Pink, Santana); University of Calgary and Tom Baker Cancer Centre, Calgary (Robinson); Faculty of Nursing, University of Calgary, Calgary (Sinclair)
| | - F Servidio-Italiano
- Ontario: Queen's Cancer Research Institute, Kingston (Brundage); Sunnybrook Health Sciences Centre, Toronto (Coburn); Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto (Howell); McMaster University, Hamilton (Klassen); CancerInsight, Oakville (Leduc); Department of Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Toronto (Li); Canadian Partnership Against Cancer, Toronto (Moxam); Colorectal Cancer Resource and Action Network, Oakville (Servidio-Italiano)
| | - W Temple
- Alberta: Department of Oncology, University of Calgary, Calgary (Barbera, Bebb, Cheung); University of Calgary, Calgary (Crump, Temple); Departments of Surgery and Oncology, University of Calgary, Calgary (McKinnon); Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary (Pink, Santana); University of Calgary and Tom Baker Cancer Centre, Calgary (Robinson); Faculty of Nursing, University of Calgary, Calgary (Sinclair)
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Woolfson JP, Schreiber R, Butler A, MacFarlane J, Kaczorowski J, Collet J, Bryan S. A335 BILIARY ATRESIA HOME SCREENING PROGRAM IN BRITISH COLUMBIA: EVALUATION OF FIRST TWO YEARS. J Can Assoc Gastroenterol 2018. [DOI: 10.1093/jcag/gwy008.336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- J P Woolfson
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, BC Children’s Hospital, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - R Schreiber
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, BC Children’s Hospital, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - A Butler
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, BC Children’s Hospital, Vancouver, BC, Canada
| | - J MacFarlane
- Perinatal Services BC, PHSA, Vancouver, BC, Canada
| | - J Kaczorowski
- Dept of Family and Emergency Medicine, Université de Montréal and CRCHUM, Montreal, QC, Canada
| | - J Collet
- Department of Pediatrics, University of British Columbia, BC Children’s Hospital Research Institute, Vancouver, BC, Canada
| | - S Bryan
- School of Population and Public Health, University of British Columbia, Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
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Trenaman L, Stacey D, Bryan S, Taljaard M, Hawker G, Dervin G, Tugwell P, Bansback N. Decision aids for patients considering total joint replacement: a cost-effectiveness analysis alongside a randomised controlled trial. Osteoarthritis Cartilage 2017. [PMID: 28624294 DOI: 10.1016/j.joca.2017.05.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Shared decision-making (SDM) is a key priority to improve patient-centred care, and can play an important role in helping patients decide whether to undergo total joint arthroplasty (TJA). Patient decision aids can support SDM; however, they may incur an upfront cost. We aimed to estimate the health and economic effects of patient decision aids for TJA. METHODS A cost-effectiveness analysis of a randomised controlled trial (RCT) with 2-year follow-up. 343 patients were recruited from two orthopedic screening clinics in Ottawa, Canada. Patients were randomized to either a patient decision aid plus surgeon preference report (decision aid) or usual care. Primary outcomes were costs (in 2014 CAD$), quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER). Costs were calculated by multiplying self-reported resource use by unit costs. QALYs were calculated by mapping the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) to EuroQol 5-Dimension (EQ-5D) health utilities. Costs and QALYs were discounted at 5%. Multiple imputation was used to handle missing data, and bootstrapping was used to estimate uncertainty. RESULTS The sample comprised 167 intervention and 167 control group patients. The decision aid arm had fewer surgeries over the 2-year period thereby incurring a negative incremental cost of -$560 (95% CI: -$1358 to $426) per patient while providing 0.05 (95% CI: -0.04 to 0.13) additional QALYs per patient. Consequently, the decision aid arm was dominant. CONCLUSION The use of a patient decision aid was associated with fewer health care costs, while producing similar health outcomes. CLINICAL TRIAL REGISTRATION NUMBER CT00911638 (clinicaltrials.gov).
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Affiliation(s)
- L Trenaman
- University of British Columbia, Vancouver, Canada; Centre for Clinical Epidemiology and Evaluation, Vancouver, Canada; Centre for Health Evaluation and Outcome Sciences, Vancouver, Canada; Arthritis Research Canada, Richmond, Canada
| | - D Stacey
- University of Ottawa, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada
| | - S Bryan
- University of British Columbia, Vancouver, Canada; Centre for Clinical Epidemiology and Evaluation, Vancouver, Canada
| | - M Taljaard
- University of Ottawa, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada
| | - G Hawker
- University of Toronto, Toronto, Canada; Women's College Hospital, Toronto, Canada
| | - G Dervin
- University of Ottawa, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada
| | - P Tugwell
- University of Ottawa, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada
| | - N Bansback
- University of British Columbia, Vancouver, Canada; Centre for Clinical Epidemiology and Evaluation, Vancouver, Canada; Centre for Health Evaluation and Outcome Sciences, Vancouver, Canada; Arthritis Research Canada, Richmond, Canada.
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Woolfson J, Schreiber R, Butler A, MacFarlane J, Kaczorowski J, Masucci L, Bryan S, Collet JP. BILIARY ATRESIA HOME SCREENING PROGRAM IN BRITISH COLUMBIA: EVALUATION OF FIRST TWO YEARS. Paediatr Child Health 2017. [DOI: 10.1093/pch/pxx086.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Pollard S, Bansback N, FitzGerld JM, Bryan S. The burden of nonadherence among adults with asthma: a role for shared decision-making. Allergy 2017; 72:705-712. [PMID: 27873330 DOI: 10.1111/all.13090] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2016] [Indexed: 01/29/2023]
Abstract
A shared approach to decision-making framework has been suggested for chronic disease management especially where multiple treatment options exist. Shared decision-making (SDM) requires that both physician and patients are actively engaged in the decision-making process, including information exchange; expressing treatment preferences; as well as agreement over the final treatment decision. Although SDM appears well supported by patients, practitioners and policymakers alike, the current challenge is to determine how best to make SDM a reality in everyday clinical practice. Within the context of asthma, adherence rates are poor and are linked to outcomes such as reduced asthma control, increased symptoms, healthcare expenditures, and lower patient quality of life. It has been suggested that SDM can improve treatment adherence and that ignoring patients' personal goals and preferences may result in reduced rates of adherence. Furthermore, understanding predictors of poor treatment adherence is a necessary step toward developing effective strategies to improve the patient-reported and clinically important outcomes. Here, we describe why a shared approach to treatment decision-making for asthma has the potential to be an effective tool for improving adherence, with associated clinical and patient-related outcomes. In addition, we explore insights into the reasons why SDM has not been implemented into routine clinical practice.
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Affiliation(s)
- S. Pollard
- School of Population and Public Health; University of British Columbia; Vancouver BC Canada
- Centre for Clinical Epidemiology and Evaluation; Vancouver Coastal Research Institute; Vancouver BC Canada
| | - N. Bansback
- School of Population and Public Health; University of British Columbia; Vancouver BC Canada
- Centre for Clinical Epidemiology and Evaluation; Vancouver Coastal Research Institute; Vancouver BC Canada
- Centre for Health Evaluation and Outcome Sciences; St Paul's Hospital; Vancouver BC Canada
| | - J. M. FitzGerld
- Centre for Clinical Epidemiology and Evaluation; Vancouver Coastal Research Institute; Vancouver BC Canada
- Institute for Heart and Lung Health; Faculty of Medicine; University of British Columbia; Vancouver BC Canada
| | - S. Bryan
- School of Population and Public Health; University of British Columbia; Vancouver BC Canada
- Centre for Clinical Epidemiology and Evaluation; Vancouver Coastal Research Institute; Vancouver BC Canada
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Davis JC, Dian L, Khan KM, Bryan S, Marra CA, Hsu CL, Jacova P, Chiu BK, Liu-Ambrose T. Cognitive status is a determinant of health resource utilization among individuals with a history of falls: a 12-month prospective cohort study. Osteoporos Int 2016; 27:943-951. [PMID: 26449355 PMCID: PMC4898957 DOI: 10.1007/s00198-015-3350-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 09/29/2015] [Indexed: 01/23/2023]
Abstract
SUMMARY Falls are a costly public health problem worldwide. The literature is devoid of prospective data that identifies factors among fallers that significantly drive health care resource utilization. We found that cognitive function--specifically, executive functions--and cognitive status are significant determinants of health resource utilization among older fallers. INTRODUCTION Although falls are costly, there are no prospective data examining factors among fallers that drive health care resource utilization. We identified key determinants of health resource utilization (HRU) at 6 and 12 months among older adults with a history of falls. Specifically, with the increasing recognition that cognitive impairment is associated with increased falls risk, we investigated cognition as a potential driver of health resource utilization. METHODS This 12-month prospective cohort study at the Vancouver Falls Prevention Clinic (n = 319) included participants with a history of at least one fall in the previous 12 months. Based on their cognitive status, participants were divided into two groups: (1) no mild cognitive impairment (MCI) and (2) MCI. We constructed two linear regression models with HRU at 6 and 12 months as the dependent variables for each model, respectively. Predictors relating to mobility, global cognition, executive functions, and cognitive status (MCI versus no MCI) were examined. Age, sex, comorbidities, depression status, and activities of daily living were included regardless of statistical significance. RESULTS Global cognition, comorbidities, working memory, and cognitive status (MCI versus no MCI ascertained using the Montreal Cognitive Assessment (MoCA)) were significant determinants of total HRU at 6 months. The number of medical comorbidities and global cognition were significant determinants of total HRU at 12 months. CONCLUSION MCI status was a determinant of HRU at 6 months among older adults with a history of falls. As such, efforts to minimize health care resource use related to falls, it is important to tailor future interventions to be effective for people with MCI who fall. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01022866.
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Affiliation(s)
- J C Davis
- Center for Hip Health and Mobility, Robert HN Ho Research Centre 2635 Laurel St, Vancouver, BC, V5Z 1M9, Canada
- Aging, Mobility, and Cognitive Neuroscience Lab, Department of Physical Therapy, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - L Dian
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - K M Khan
- Center for Hip Health and Mobility, Robert HN Ho Research Centre 2635 Laurel St, Vancouver, BC, V5Z 1M9, Canada
| | - S Bryan
- Centre for Clinical Epidemiology and Evaluation, University of British Columbia & VCHRI, 828 West 10th Avenue, Vancouver, BC, V6T 2B5, Canada
| | - C A Marra
- School of Pharmacy, Memorial University, St. John's, NF, Canada
| | - C L Hsu
- Center for Hip Health and Mobility, Robert HN Ho Research Centre 2635 Laurel St, Vancouver, BC, V5Z 1M9, Canada
- Aging, Mobility, and Cognitive Neuroscience Lab, Department of Physical Therapy, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - P Jacova
- Center for Hip Health and Mobility, Robert HN Ho Research Centre 2635 Laurel St, Vancouver, BC, V5Z 1M9, Canada
- Aging, Mobility, and Cognitive Neuroscience Lab, Department of Physical Therapy, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - B K Chiu
- Center for Hip Health and Mobility, Robert HN Ho Research Centre 2635 Laurel St, Vancouver, BC, V5Z 1M9, Canada
- Aging, Mobility, and Cognitive Neuroscience Lab, Department of Physical Therapy, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - T Liu-Ambrose
- Center for Hip Health and Mobility, Robert HN Ho Research Centre 2635 Laurel St, Vancouver, BC, V5Z 1M9, Canada.
- Aging, Mobility, and Cognitive Neuroscience Lab, Department of Physical Therapy, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
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Bracey E, Chave H, Agombar A, Sleight S, Dukes S, Bryan S, Branagan G. Ileostomy closure in an enhanced recovery setting. Colorectal Dis 2015; 17:917-21. [PMID: 25950922 DOI: 10.1111/codi.12989] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/03/2015] [Indexed: 02/08/2023]
Abstract
AIM Hospital stays of 5 days or more are not uncommon following ileostomy closure, yet within an enhanced recovery programme (ERP) it is possible for patients to be discharged on the first postoperative day following anterior resection. The aim of this study was to evaluate whether the introduction of an ERP for ileostomy closure reduced hospital stay without affecting morbidity or readmission rates. METHOD Consecutive patients undergoing elective ileostomy closure from October 2000 to March 2013 were included in this study. The data were collected prospectively into a database. Enhanced recovery was introduced for all elective ileostomy closures in June 2010. Demographic data, length of stay (LOS), readmission, morbidity and mortality were compared between the two groups using the Mann-Whitney U-test and Fisher's exact test. RESULTS One hundred and forty-five patients underwent elective ileostomy closure during the study period (37 ERP and 108 pre-ERP). There were no differences between the two groups with respect to demographics, American Society of Anesthesiologists grade, prior radiotherapy or chemotherapy, operative time, body mass index, antibiotic use or closure method. Readmission rates (5% vs 6.5%, P = 1.0), morbidity (8% vs 10%, P = 1.0) and mortality (0% vs 0%) were not significantly different. Median (2 vs 4 days, P < 0.0001) and mean (3.4 vs 5.6 days, P = 0.033) LOS were significantly shorter in the ERP group compared with the pre-ERP group. CONCLUSION An ERP for closure of ileostomy significantly reduces LOS without adverse effects for patients.
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Affiliation(s)
- E Bracey
- Department of Colorectal Surgery, Salisbury District Hospital, Salisbury, UK
| | - H Chave
- Department of Colorectal Surgery, Salisbury District Hospital, Salisbury, UK
| | - A Agombar
- Department of Colorectal Surgery, Salisbury District Hospital, Salisbury, UK
| | - S Sleight
- Department of Colorectal Surgery, Salisbury District Hospital, Salisbury, UK
| | - S Dukes
- Department of Colorectal Surgery, Salisbury District Hospital, Salisbury, UK
| | - S Bryan
- Department of Colorectal Surgery, Salisbury District Hospital, Salisbury, UK
| | - G Branagan
- Department of Colorectal Surgery, Salisbury District Hospital, Salisbury, UK
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Reuther W, Bryan S, Al-Gholmy M, Anand R, Brennan P. Incidence of Peroneal Nerve Injury Following the use of Anti Thrombo-embolic Deterrent Stockings (TEDS) in Maxillofacial Patients. Br J Oral Maxillofac Surg 2014. [DOI: 10.1016/j.bjoms.2014.07.214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Bryan S, Lim J, Mackenzie N. Piercings: Grossly swollen tongue. Br Dent J 2014; 216:210-1. [PMID: 24603223 DOI: 10.1038/sj.bdj.2014.152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Shamji M, Moon ES, Glennie R, Soroceanu A, Lin C, Bailey C, Simmonds A, Fehlings M, Dodwell E, Dold A, El-Hawary R, Hashem M, Dold A, Dold A, Jones S, Bailey C, Karadimas S, Whitehurst D, Norton J, Norton J, Manson N, Kesani A, Bednar D, Lundine K, Hartig D, Fichadi A, Fehlings M, Kim S, Harris S, Lin C, Gill J, Abraham E, Shamji M, Choi S, Goldstein C, Wang Z, McCabe M, Noonan V, Nadeau M, Ferrara S, Kelly A, Melnyk A, Arora D, Quateen A, Dea N, Ranganathan A, Zhang Y, Casha S, Rajamanickam K, Santos A, Santos A, Wilson J, Wilson J, Street J, Wilson J, Lewis R, Noonan V, Street J, El-Hawary R, Egge N, Lin C, Schouten R, Lin C, Kim A, Kwon B, Huang E, Hwang P, Allen K, Jing L, Mata B, Gabr M, Richardson W, Setton L, Karadimas S, Fehlings M, Fleming J, Bailey C, Gurr K, Bailey S, Siddiqi F, Lawendy A, Sanders D, Staudt M, Canacari E, Brown E, Robinson A, McGuire K, Chrysostoum C, Rampersaud YR, Dvorak M, Thomas K, Boyd M, Gurr K, Bailey S, Nadeau M, Fisher C, Batke J, Street J, Boyd M, Dvorak M, Fisher C, Kwon B, Paquette S, Vaccaro A, Chapman J, Arnold P, Shaffrey C, Kopjar B, Snyder B, Wright J, Lewis S, Zeller R, El-Hawary R, Moroz P, Bacon S, Jarzem P, Hedden D, Howard J, Sturm P, Cahill P, Samdani A, Vitale M, Gabos P, Bodin N, d’Amato C, Harris C, Smith J, Parent E, Hill D, Hedden D, Moreau M, Mahood J, Lewis S, Bodrogi A, Abbas H, Goldstein S, Bronstein Y, Bacon S, Chua S, Magana S, Van Houwelingen A, Halpern E, Jhaveri S, Lewis S, Lim A, Leelapattana P, Fleming J, Siddiqqi F, Bailey S, Gurr K, Moon ES, Satkunendrarajah K, Fehlings M, Noonan V, Dvorak M, Bryan S, Aronyk K, Fox R, Nataraj A, Pugh J, Elliott R, McKeon M, Abraham E, Fleming J, Gurr K, Bailey S, Siddiqi F, Bailey C, Davis G, Rogers M, Staples M, Quan G, Batke J, Boyd M, Dvorak M, Fisher C, Kwon B, Paquette S, Street J, Shamji M, Hurlbert R, Jacobs W, Duplessis S, Casha S, Jha N, Hewson S, Massicotte E, Kopjar B, Mortaz S, Coyte P, Rampersaud Y, Rampersaud Y, Goldstein S, Andrew B, Modi H, Magana S, Lewis S, Roffey D, Miles I, Wai E, Manson N, Eastwood D, Elliot R, McKeon M, Bains I, Yong E, Sutherland G, Hurlbert R, Rampersaud Y, Chan V, Persaud O, Koshkin A, Brull R, Hassan N, Petis S, Kowalczuk M, Petrisor B, Drew B, Bhandari M, DiPaola C, Boyd M, Dvorak M, Fisher C, Kwon B, Paquette S, Street J, McLachlin S, Bailey S, Gurr K, Bailey C, Dunning C, Fehlings M, Vaccaro A, Wing P, Itshayek E, Biering-Sorensen F, Dvorak M, McLachlin S, Bailey S, Gurr K, Dunning C, Bailey C, Bradi A, Pokrupa R, Batke J, Boyd M, Dvorak M, Fisher C, Kwon B, Paquette S, Street J, Kelly A, Wen T, Kingwell S, Chak J, Singh V, Cripton P, Fisher C, Dvorak M, Oxland T, Wali Z, Yen D, Alfllouse A, Alzahrani A, Jiang H, Mahood J, Kortbeek F, Fox R, Nataraj A, Street J, Boyd M, Paquette S, Kwon B, Batke J, Dvorak M, Fisher C, Reddy R, Rampersaud R, Hurlbert J, Yong W, Casha S, Zygun D, McGowan D, Bains I, Yong V, Hurlbert R, Mendis B, Chakraborty S, Nguyen T, Tsai E, Chen A, Atkins D, Noonan V, Drew B, Tsui D, Townson A, Dvorak M, Chen A, Atkins D, Noonan V, Drew B, Dvorak M, Craven C, Ford M, Ahn H, Drew B, Fehlings M, Kiss A, Vaccaro A, Harrop J, Grossman R, Frankowski R, Guest J, Dvorak M, Aarabi B, Fehlings M, Noonan V, Cheung A, Sun B, Dvorak M, Vaccaro A, Harrop J, Massicotte E, Dvorak M, Fisher C, Rampersaud R, Lewis S, Fehlings M, Marais L, Noonan V, Queyranne M, Fehlings M, Dvorak M, Atkins D, Hurlbert R, Fox R, Fourney D, Johnson M, Fehlings M, Ahn H, Ford M, Yee A, Finkelstein J, Tsai E, Bailey C, Drew B, Paquet J, Parent S, Christie S, Dvorak M, Noonan V, Cheung A, Sun B, Dvorak M, Sturm P, Cahill P, Samdani A, Vitale M, Gabos P, Bodin N, d’Amato C, Harris C, Smith J, Lange J, DiPaola C, Lapinsky A, Connolly P, Eck J, Rabin D, Zeller R, Lewis S, Lee R, Boyd M, Dvorak M, Fisher C, Kwon B, Paquette S, DiPaola C, Street J, Bodrogi A, Goldstein S, Sofia M, Lewis S, Shin J, Tung K, Ahn H, Lee R, Batke J, Ghag R, Noonan V, Dvorak M, Goyal T, Littlewood J, Bains I, Cho R, Thomas K, Swamy G. Canadian Spine Society abstracts1.1.01 Supraspinal modulation of gait abnormalities associated with noncompressive radiculopathy may be mediated by altered neurotransmitter sensitivity1.1.02 Neuroprotective effects of the sodium-glutamate blocker riluzole in the setting of experimental chronic spondylotic myelopathy1.1.03 The effect of timing to decompression in cauda equina syndrome using a rat model1.2.04 Intraoperative waste in spine surgery: incidence, cost and effectiveness of an educational program1.2.05 Looking beyond the clinical box: the health services impact of surgical adverse events1.2.06 Brace versus no brace for the treatment of thoracolumbar burst fractures without neurologic injury: a multicentre prospective randomized controlled trial1.2.07 Adverse event rates in surgically treated spine injuries without neurologic deficit1.2.08 Functional and quality of life outcomes in geriatric patients with type II odontoid fracture: 1-year results from the AOSpine North America Multi-Center Prospective GOF Study1.3.09 National US practices in pediatric spinal fusion: in-hospital complications, length of stay, mortality, costs and BMP utilization1.3.10 Current trends in the surgical treatment of adolescent idiopathic scoliosis in Canada1.3.11 Sagittal spinopelvic parameters help predict the risk of proximal junctional kyphosis for children treated with posterior distraction-based implants1.4.12 Correlations between changes in surface topography and changes in radiograph measurements from before to 6 months after surgery in adolescents with idiopathic scoliosis1.4.13 High upper instrumented vertebra (UIV) sagittal angle is associated with UIV fracture in adult deformity corrections1.4.14 Correction of adult idiopathic scoliosis using intraoperative skeletal traction1.5.01 Cauda equina: using management protocols to reduce delays in diagnosis1.5.02 Predicting the need for tracheostomy in patients with acute traumatic spinal cord injury1.5.03 A novel animal model of cervical spondylotic myelopathy: an opportunity to identify new therapeutic targets1.5.04 A review of preference-based measures of health-related quality of life in spinal cord injury research1.5.05 Predicting postoperative neuropathic pain following surgery involving nerve root manipulation based on intraoperative electromyographic activity1.5.06 Detecting positional injuries in prone spinal surgery1.5.07 Percutaneous thoracolumbar stabilization for trauma: surgical morbidity, clinical outcomes and revision surgery1.5.08 Systemic inflammatory response syndrome in spinal cord injury patients: Does its presence at admission affect patient outcomes?2.1.15 One hundred years of spine surgery — a review of the evolution of our craft and practice in the spine surgical century [presentation]2.1.16 Prevalence of preoperative MRI findings of adjacent segment disc degeneration in patients undergoing anterior cervical discectomy and fusion2.1.17 Adverse event rates of surgically treated cervical spondylopathic myelopathy2.1.18 Morphometricand dynamic changes in the cervical spine following anterior cervical discectomy and fusion and cervical disc arthroplasty2.1.19 Is surgery for cervical spondylotic myelopathy cost-effective? A cost–utility analysis based on data from the AO Spine North American Prospective Multicentre CSM Study2.2.20 Cost–utility of lumbar decompression with or without fusion for patients with symptomatic degenerative lumbar spondylolisthesis (DLS)2.2.21 Minimally invasive surgery lumbar fusion for low-grade isthmic and degenerative spondylolisthesis: 2- to 5-year follow-up2.2.22 Results and complications of posterior-only reduction and fusion for high-grade spondylolisthesis2.3.23 Fusion versus no fusion in patients with central lumbar spinal stenosis and foraminal stenosis undergoing decompression surgery: comparison of outcomes at baseline and follow-up2.3.24 Two-year results of interspinous spacers (DIAM) as an alternative to arthrodesis for lumbar degenerative disorders2.3.25 Treatment of herniated lumbar disc by sequestrectomy or conventional discectomy2.4.26 No sustained benefit of continuous epidural analgesia for minimally invasive lumbar fusion: a randomized double-blinded placebo controlled study2.4.27 Evidence and current practice in the radiologic assessment of lumbar spine fusion2.4.28 Wiltse versus midline approach for decompression and fusion of the lumbar spine2.5.09 The effect of soft tissue restraints following type II odontoid fractures in the elderly — a biomechanical study2.5.10 Development of an international spinal cord injury (SCI) spinal column injury basic data set2.5.11 Evaluation of instrumentation techniques for a unilateral facet perch and fracture using a validated soft tissue injury model2.5.12 Decreasing neurologic consequences in patients with spinal infection: the testing of a novel diagnostic guideline2.5.13 Prospective analysis of adverse events in surgical treatment of degenerative spondylolisthesis2.5.14 Load transfer characteristics between posterior fusion devices and the lumbar spine under anterior shear loading: an in vitro investigation2.5.15 Preoperative predictive clinical and radiographic factors influencing functional outcome after lumbar discectomy2.5.16 A Thoracolumbar Injury Classification and Severity Score (TLICS) of 4: What should we really do?3.1.29 Adverse events in emergent oncologic spine surgery: a prospective analysis3.1.30 En-bloc resection of primary spinal and paraspinal tumours with critical vascular involvement3.1.31 The treatment impact of minocycline on quantitative MRI in acute spinal cord injury3.1.32 Benefit of minocycline in spinal cord injury — results of a double-blind randomized placebo-controlled study3.2.33 Improvement of magnetic resonance imaging correlation with unilateral motor or sensory deficits using diffusion tensor imaging3.2.34 Comparing care delivery for acute traumatic spinal cord injury in 2 Canadian centres: How do the processes of care differ?3.2.35 Improving access to early surgery: a comparison of 2 centres3.3.36 The effects of early surgical decompression on motor recovery after traumatic spinal cord injury: results of a Canadian multicentre study3.3.37 A clinical prediction model for long-term functional outcome after traumatic spinal cord injury based on acute clinical and imaging factors3.3.38 Effect of motor score on adverse events and quality of life in patients with traumatic spinal cord injury3.4.39 The impact of facet dislocation on neurologic recovery after cervical spinal cord injury: an analysis of data on 325 patients from the Surgical Trial in Acute Spinal Cord Injury Study (STASCIS)3.4.40 Toward a more precise understanding of the epidemiology of traumatic spinal cord injury in Canada3.4.41 Access to care (ACT) for traumatic SCI: a survey of acute Canadian spine centres3.4.42 Use of the Spine Adverse Events Severity (SAVES) instrument for traumatic spinal cord injury3.5.17 Does the type of distraction-based growing system for early onset scoliosis affect postoperative sagittal alignment?3.5.18 Comparison of radiation exposure during thoracolumbar fusion using fluoroscopic guidance versus anatomic placement of pedicle screws3.5.19 Skeletal traction for intraoperative reduction in adolescent idiopathic scoliosis3.5.20 Utility of intraoperative cone-beam computed tomography (O-ARM) and stereotactic navigation in acute spinal trauma surgery3.5.21 Use of a central compression rod to reduce thoracic level spinal osteotomies3.5.22 ICD-10 coding accuracy for spinal cord injured patients3.5.23 Feasibility of patient recruitment in acute SCI trials3.5.24 Treatment of adult degenerative scoliosis with DLIF approaches. Can J Surg 2012. [DOI: 10.1503/cjs.012212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Whitehurst DGT, Noonan VK, Dvorak MFS, Bryan S. A review of preference-based health-related quality of life questionnaires in spinal cord injury research. Spinal Cord 2012; 50:646-54. [DOI: 10.1038/sc.2012.46] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Bryan S, Andronis L, Hyde C, Connock M, Fry-Smith A, Wang D. Infliximab for the treatment of acute exacerbations of ulcerative colitis. Health Technol Assess 2011; 14 Suppl 1:9-15. [PMID: 20507798 DOI: 10.3310/hta14suppl1/02] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of infliximab for the treatment of acute exacerbations of ulcerative colitis, in accordance with the licensed indication, based upon the manufacturer's submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal process. The submitted clinical evidence included four randomised controlled trials (RCTs), two comparing infliximab with placebo in patients not responsive to initial treatment with intravenous corticosteroids and one comparing ciclosporin with placebo. A fourth RCT compared ciclosporin with intravenous corticosteroids as the initial treatment after hospitalisation. The manufacturer's submission concluded that infliximab provides clinical benefit to patients with acute severe, steroid-refractory ulcerative colitis and is well tolerated; it also provides additional clinical benefits over ciclosporin, particularly avoidance of colectomy. A decision tree model was built to compare infliximab with strategies involving ciclosporin, standard care and surgery. After correcting a small number of errors in the model, the revised base-case incremental cost-effectiveness ratio (ICER) for infliximab compared with standard care was 20,000 pounds. However, sensitivity analyses revealed considerable uncertainty emanating from the weight of the patient, the timeframe considered and, most importantly, the colectomy rates used. When a more appropriate mix of trials were included in the estimation of colectomy rates, the ICER for infliximab rose to 48,000 pounds. The guidance issued by NICE on 31 October 2008 states that infliximab is recommended as an option for the treatment of acute exacerbations of severely active ulcerative colitis only in patients in whom ciclosporin is contraindicated or clinically inappropriate, based on a careful assessment of the risks and benefits of treatment in the individual patient; for people who do not meet this criterion, infliximab should only be used for the treatment of acute exacerbations of severely active ulcerative colitis in clinical trials.
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Affiliation(s)
- S Bryan
- West Midlands Health Technology Assessment Collaboration, Department of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, UK
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Kaambwa B, Bryan S, Gray J, Milner P, Daniels J, Khan KS, Roberts TE. Cost-effectiveness of rapid tests and other existing strategies for screening and management of early-onset group B streptococcus during labour. BJOG 2010; 117:1616-27. [DOI: 10.1111/j.1471-0528.2010.02752.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hyde C, Bryan S, Juarez-Garcia A, Andronis L, Fry-Smith A. Infliximab for the treatment of ulcerative colitis. Health Technol Assess 2010; 13 Suppl 3:7-11. [PMID: 19846023 DOI: 10.3310/hta13suppl3/02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of infliximab for moderately to severely active ulcerative colitis (UC) based upon a review of the manufacturer's submission to the National Institute for Health and Clinical Excellent (NICE) as part of the single technology appraisal (STA) process. The submission indicated that the efficacy of infliximab (5 mg/kg) had been demonstrated in terms of higher response rates and a sustained response in health-related quality of life. For the cost-effectiveness analysis, the manufacturer built a Markov model to compare infliximab with standard care. It estimated the incremental cost per quality-adjusted life-year (QALY) gained was between 25,044 pounds and 33,866 pounds depending on the strategy used. The ERG report generally agreed with the evidence on effectiveness of infliximab for subacute exacerbations of UC. However, there were several areas of uncertainty, of which the interpretation of the importance of the quality of life changes in the subacute situation and the assessment of the adequacy of the evidence of effectiveness of infliximab in the acute hospital-based situation were considered pre-eminent by the ERG. This challenged the estimates of cost-effectiveness offered and suggested that there should be a separate assessment of infliximab for acute exacerbations of moderately to severely active UC. The summary of the NICE guidance issued in April 2008 as a result of the STA states that: infliximab is not recommended for the treatment of subacute manifestations of moderately to severely active UC.
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Affiliation(s)
- C Hyde
- West Midlands Health Technology Assessment Collaboration, Department of Public Health and Epidemiology, University of Birmingham, UK.
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Jones M, McManus RJ, Hobbs FDR, Mant J, Williams B, Bryan S, Little P, Bray EP, Greenfield SM, Holder R, Grant S, Virdee S. A RANDOMISED CONTROLLED TRIAL OF TELEMONITORING AND SELF MANAGEMENT IN THE CONTROL OF HYPERTENSION: TELEMONITORING AND SELF MANAGEMENT IN HYPERTENSION (TASMINH2): QUALITATIVE STUDY: PP.14.20. J Hypertens 2010. [DOI: 10.1097/01.hjh.0000378946.57039.9d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bryan S, Andronis L, Hyde C, Connock M, Fry-Smith A, Wang D. Infliximab for the treatment of acute exacerbations of ulcerative colitis. Health Technol Assess 2010. [DOI: 10.3310/hta14suppl1-02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of infliximab for the treatment of acute exacerbations of ulcerative colitis, in accordance with the licensed indication, based upon the manufacturer’s submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal process. The submitted clinical evidence included four randomised controlled trials (RCTs), two comparing infliximab with placebo in patients not responsive to initial treatment with intravenous corticosteroids and one comparing ciclosporin with placebo. A fourth RCT compared ciclosporin with intravenous corticosteroids as the initial treatment after hospitalisation. The manufacturer’s submission concluded that infliximab provides clinical benefit to patients with acute severe, steroid-refractory ulcerative colitis and is well tolerated; it also provides additional clinical benefits over ciclosporin, particularly avoidance of colectomy. A decision tree model was built to compare infliximab with strategies involving ciclosporin, standard care and surgery. After correcting a small number of errors in the model, the revised base-case incremental cost-effectiveness ratio (ICER) for infliximab compared with standard care was £20,000. However, sensitivity analyses revealed considerable uncertainty emanating from the weight of the patient, the timeframe considered and, most importantly, the colectomy rates used. When a more appropriate mix of trials were included in the estimation of colectomy rates, the ICER for infliximab rose to £48,000. The guidance issued by NICE on 31 October 2008 states that infliximab is recommended as an option for the treatment of acute exacerbations of severely active ulcerative colitis only in patients in whom ciclosporin is contraindicated or clinically inappropriate, based on a careful assessment of the risks and benefits of treatment in the individual patient; for people who do not meet this criterion, infliximab should only be used for the treatment of acute exacerbations of severely active ulcerative colitis in clinical trials.
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Affiliation(s)
- S Bryan
- West Midlands Health Technology Assessment Collaboration, Department of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, UK
| | - L Andronis
- West Midlands Health Technology Assessment Collaboration, Department of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, UK
| | - C Hyde
- West Midlands Health Technology Assessment Collaboration, Department of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, UK
| | - M Connock
- West Midlands Health Technology Assessment Collaboration, Department of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, UK
| | - A Fry-Smith
- West Midlands Health Technology Assessment Collaboration, Department of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, UK
| | - D Wang
- West Midlands Health Technology Assessment Collaboration, Department of Public Health and Epidemiology, University of Birmingham, Edgbaston, Birmingham, UK
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Dormandy E, Bryan S, Gulliford MC, Roberts TE, Ades AE, Calnan M, Atkin K, Karnon J, Barton PM, Logan J, Kavalier F, Harris HJ, Johnston TA, Anionwu EN, Davis V, Brown K, Juarez-Garcia A, Tsianakas V, Marteau TM. Antenatal screening for haemoglobinopathies in primary care: a cohort study and cluster randomised trial to inform a simulation model. The Screening for Haemoglobinopathies in First Trimester (SHIFT) trial. Health Technol Assess 2010; 14:1-160. [DOI: 10.3310/hta14200] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- E Dormandy
- Department of Psychology at Guy's, Health Psychology Section, Institute of Psychiatry, King's College London, UK
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Daniels J, Gray J, Pattison H, Roberts T, Edwards E, Milner P, Spicer L, King E, Hills RK, Gray R, Buckley L, Magill L, Elliman N, Kaambwa B, Bryan S, Howard R, Thompson P, Khan KS. Rapid testing for group B streptococcus during labour: a test accuracy study with evaluation of acceptability and cost-effectiveness. Health Technol Assess 2009; 13:1-154, iii-iv. [PMID: 19778493 DOI: 10.3310/hta13420] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To determine the accuracy, acceptability and cost-effectiveness of polymerase chain reaction (PCR) and optical immunoassay (OIA) rapid tests for maternal group B streptococcal (GBS) colonisation at labour. DESIGN A test accuracy study was used to determine the accuracy of rapid tests for GBS colonisation of women in labour. Acceptability of testing to participants was evaluated through a questionnaire administered after delivery, and acceptability to staff through focus groups. A decision-analytic model was constructed to assess the cost-effectiveness of various screening strategies. SETTING Two large obstetric units in the UK. PARTICIPANTS Women booked for delivery at the participating units other than those electing for a Caesarean delivery. INTERVENTIONS Vaginal and rectal swabs were obtained at the onset of labour and the results of vaginal and rectal PCR and OIA (index) tests were compared with the reference standard of enriched culture of combined vaginal and rectal swabs. MAIN OUTCOME MEASURES The accuracy of the index tests, the relative accuracies of tests on vaginal and rectal swabs and whether test accuracy varied according to the presence or absence of maternal risk factors. RESULTS PCR was significantly more accurate than OIA for the detection of maternal GBS colonisation. Combined vaginal or rectal swab index tests were more sensitive than either test considered individually [combined swab sensitivity for PCR 84% (95% CI 79-88%); vaginal swab 58% (52-64%); rectal swab 71% (66-76%)]. The highest sensitivity for PCR came at the cost of lower specificity [combined specificity 87% (95% CI 85-89%); vaginal swab 92% (90-94%); rectal swab 92% (90-93%)]. The sensitivity and specificity of rapid tests varied according to the presence or absence of maternal risk factors, but not consistently. PCR results were determinants of neonatal GBS colonisation, but maternal risk factors were not. Overall levels of acceptability for rapid testing amongst participants were high. Vaginal swabs were more acceptable than rectal swabs. South Asian women were least likely to have participated in the study and were less happy with the sampling procedure and with the prospect of rapid testing as part of routine care. Midwives were generally positive towards rapid testing but had concerns that it might lead to overtreatment and unnecessary interference in births. Modelling analysis revealed that the most cost-effective strategy was to provide routine intravenous antibiotic prophylaxis (IAP) to all women without screening. Removing this strategy, which is unlikely to be acceptable to most women and midwives, resulted in screening, based on a culture test at 35-37 weeks' gestation, with the provision of antibiotics to all women who screened positive being most cost-effective, assuming that all women in premature labour would receive IAP. The results were sensitive to very small increases in costs and changes in other assumptions. Screening using a rapid test was not cost-effective based on its current sensitivity, specificity and cost. CONCLUSIONS Neither rapid test was sufficiently accurate to recommend it for routine use in clinical practice. IAP directed by screening with enriched culture at 35-37 weeks' gestation is likely to be the most acceptable cost-effective strategy, although it is premature to suggest the implementation of this strategy at present.
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Affiliation(s)
- J Daniels
- University of Birmingham, Academic Department of Obstetrics and Gynaecology, Birmingham Women's Hospital, UK
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Evans HER, Tsourapas A, Mercer CH, Rait G, Bryan S, Hamill M, Delpech V, Hughes G, Brook G, Williams T, Johnson AM, Singh S, Petersen I, Chadborn T, Cassell JA. Primary care consultations and costs among HIV-positive individuals in UK primary care 1995-2005: a cohort study. Sex Transm Infect 2009; 85:543-9. [DOI: 10.1136/sti.2009.035865] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of infliximab for moderately to severely active ulcerative colitis (UC) based upon a review of the manufacturer’s submission to the National Institute for Health and Clinical Excellent (NICE) as part of the single technology appraisal (STA) process. The submission indicated that the efficacy of infliximab (5 mg/kg) had been demonstrated in terms of higher response rates and a sustained response in health-related quality of life. For the cost-effectiveness analysis, the manufacturer built a Markov model to compare infliximab with standard care. It estimated the incremental cost per quality-adjusted life-year (QALY) gained was between £25,044 and £33,866 depending on the strategy used. The ERG report generally agreed with the evidence on effectiveness of infliximab for subacute exacerbations of UC. However, there were several areas of uncertainty, of which the interpretation of the importance of the quality of life changes in the subacute situation and the assessment of the adequacy of the evidence of effectiveness of infliximab in the acute hospital-based situation were considered pre-eminent by the ERG. This challenged the estimates of cost-effectiveness offered and suggested that there should be a separate assessment of infliximab for acute exacerbations of moderately to severely active UC. The summary of the NICE guidance issued in April 2008 as a result of the STA states that: infliximab is not recommended for the treatment of subacute manifestations of moderately to severely active UC.
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Affiliation(s)
- C Hyde
- West Midlands Health Technology Assessment Collaboration, Department of Public Health and Epidemiology, University of Birmingham, UK
| | - S Bryan
- West Midlands Health Technology Assessment Collaboration, Department of Public Health and Epidemiology, University of Birmingham, UK
| | - A Juarez-Garcia
- West Midlands Health Technology Assessment Collaboration, Department of Public Health and Epidemiology, University of Birmingham, UK
| | - L Andronis
- West Midlands Health Technology Assessment Collaboration, Department of Public Health and Epidemiology, University of Birmingham, UK
| | - A Fry-Smith
- West Midlands Health Technology Assessment Collaboration, Department of Public Health and Epidemiology, University of Birmingham, UK
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Clarke CE, Furmston A, Morgan E, Patel S, Sackley C, Walker M, Bryan S, Wheatley K. Pilot randomised controlled trial of occupational therapy to optimise independence in Parkinson's disease: the PD OT trial. J Neurol Neurosurg Psychiatry 2009; 80:976-8. [PMID: 18339727 DOI: 10.1136/jnnp.2007.138586] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To perform a pilot trial of occupational therapy (OT) to optimise functional independence in Parkinson disease (PD) to assess accrual/withdrawal rates, acceptability, outcome measures, and inform sample-size calculation. METHOD Non-demented patients with idiopathic PD and difficulties with activities of daily living (ADL) were recruited provided they had not received OT in the last 2 years and/or physiotherapy in the last year. Patients were randomised to immediate OT or OT after completion of the trial. Patients randomised to OT were assessed at home by an experienced therapist and then received six home treatment sessions over 2 months. Interventions were targeted at functional independence and mobility goals. Outcome measures were: Nottingham Extended Activity of Daily Living Scale, Rivermead Mobility Index, Unified Parkinson's Disease Rating Scale ADL scale, Parkinson's Disease Questionnaire 39, EuroQol-EQ-5D, Hospital Anxiety and Depression Scale, and health economics analysis. RESULTS 39 patients (25 male; mean age 73 years) were recruited from four centres over 16 months. The mean difference in NEADL at 8 months was 3.5 (95% CI -3.2 to 10.2). The mean difference in PDQ-39 Summary Score was 3.8 (95% CI -4.94 to 12.6). There were strong correlations between the PDQ-39 and other outcomes. The intervention was acceptable to patients, with a low withdrawal rate and good questionnaire completion. CONCLUSION Randomisation to a trial of OT in PD is feasible. NEADL and PDQ-39 are relevant outcomes and provided data to inform sample size for an adequately powered randomised trial for which there is pressing need.
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Affiliation(s)
- C E Clarke
- Department of Neurology, City Hospital, Dudley Road, Birmingham B18 7QH, UK.
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Jowett S, Bryan S, Poller L, VAN DEN Besselaar AMHP, VAN DER Meer FJM, Palareti G, Shiach C, Tripodi A, Keown M, Ibrahim S, Lowe G, Moia M, Turpie AG, Jespersen J. The cost-effectiveness of computer-assisted anticoagulant dosage: results from the European Action on Anticoagulation (EAA) multicentre study. J Thromb Haemost 2009; 7:1482-90. [PMID: 19515090 DOI: 10.1111/j.1538-7836.2009.03508.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Increased demand for oral anticoagulation has resulted in wider adoption of computer-assisted dosing in anticoagulant clinics. An economic evaluation has been performed to investigate the cost-effectiveness of computer-assisted dosing in comparison with manual dosing in patients on oral anticoagulant therapy. METHODS A trial-based cost-effectiveness analysis was conducted as part of the EAA randomized study of computer-assisted dosage vs. manual dosing. The 4.5-year multinational trial was conducted in 32 centres with 13 219 anticoagulation patients randomized to manual or computer-assisted dosage. The main outcome measures were total health care costs, clinical event rates and cost-saving per clinical event prevented by computer dosing compared with manual dosing. RESULTS Mean dosing costs per patient were lower (difference: euro47) for computer-assisted dosing, but with little difference in clinical event costs. Total overall costs were euro51 lower in the computer-assisted dosing arm. There were a larger number of clinical events in the manual dosing arm. The overall difference between trial arms was not significant (difference in clinical events, -0.003; 95% CI, -0.010-0.004) but there was a significant reduction in events with DVT/PE, suggesting computer-assisted dosage with the two study programs (dawn ac or parma 5) was at least as effective clinically as manual dosage. The cost-effectiveness analysis indicated that computer-assisted dosing is less costly than manual dosing. CONCLUSIONS Results indicate that computer-assisted dosage with the two programs (dawn ac and parma 5) is cheaper than manual dosage and is at least as effective clinically, indicating that investment in this technology represents value for money.
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Affiliation(s)
- S Jowett
- Health Economics, School of Health and Population Sciences, University of Birmingham, Birmingham.
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Andronis L, Barton P, Bryan S. Sensitivity analysis in economic evaluation: an audit of NICE current practice and a review of its use and value in decision-making. Health Technol Assess 2009; 13:iii, ix-xi, 1-61. [PMID: 19500484 DOI: 10.3310/hta13290] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To determine how we define good practice in sensitivity analysis in general and probabilistic sensitivity analysis (PSA) in particular, and to what extent it has been adhered to in the independent economic evaluations undertaken for the National Institute for Health and Clinical Excellence (NICE) over recent years; to establish what policy impact sensitivity analysis has in the context of NICE, and policy-makers' views on sensitivity analysis and uncertainty, and what use is made of sensitivity analysis in policy decision-making. DATA SOURCES Three major electronic databases, MEDLINE, EMBASE and the NHS Economic Evaluation Database, were searched from inception to February 2008. REVIEW METHODS The meaning of 'good practice' in the broad area of sensitivity analysis was explored through a review of the literature. An audit was undertaken of the 15 most recent NICE multiple technology appraisal judgements and their related reports to assess how sensitivity analysis has been undertaken by independent academic teams for NICE. A review of the policy and guidance documents issued by NICE aimed to assess the policy impact of the sensitivity analysis and the PSA in particular. Qualitative interview data from NICE Technology Appraisal Committee members, collected as part of an earlier study, were also analysed to assess the value attached to the sensitivity analysis components of the economic analyses conducted for NICE. RESULTS All forms of sensitivity analysis, notably both deterministic and probabilistic approaches, have their supporters and their detractors. Practice in relation to univariate sensitivity analysis is highly variable, with considerable lack of clarity in relation to the methods used and the basis of the ranges employed. In relation to PSA, there is a high level of variability in the form of distribution used for similar parameters, and the justification for such choices is rarely given. Virtually all analyses failed to consider correlations within the PSA, and this is an area of concern. Uncertainty is considered explicitly in the process of arriving at a decision by the NICE Technology Appraisal Committee, and a correlation between high levels of uncertainty and negative decisions was indicated. The findings suggest considerable value in deterministic sensitivity analysis. Such analyses serve to highlight which model parameters are critical to driving a decision. Strong support was expressed for PSA, principally because it provides an indication of the parameter uncertainty around the incremental cost-effectiveness ratio. CONCLUSIONS The review and the policy impact assessment focused exclusively on documentary evidence, excluding other sources that might have revealed further insights on this issue. In seeking to address parameter uncertainty, both deterministic and probabilistic sensitivity analyses should be used. It is evident that some cost-effectiveness work, especially around the sensitivity analysis components, represents a challenge in making it accessible to those making decisions. This speaks to the training agenda for those sitting on such decision-making bodies, and to the importance of clear presentation of analyses by the academic community.
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Affiliation(s)
- L Andronis
- Department of Health Economics, University of Birmingham, UK
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Bryan S. Balancing Cost-Effectiveness with other Values: Experiences of the National Institute for Health and Clinical Excellence (NICE). Gesundheitswesen 2009. [DOI: 10.1055/s-0029-1220696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Chen YF, Jobanputra P, Barton P, Bryan S, Fry-Smith A, Harris G, Taylor RS. Cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs (etodolac, meloxicam, celecoxib, rofecoxib, etoricoxib, valdecoxib and lumiracoxib) for osteoarthritis and rheumatoid arthritis: a systematic review and economic evaluation. Health Technol Assess 2008; 12:1-278, iii. [PMID: 18405470 DOI: 10.3310/hta12110] [Citation(s) in RCA: 195] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To review the clinical effectiveness and cost-effectiveness of cyclooxygenase-2 (COX-2) selective non-steroidal anti-inflammatory drugs (NSAIDs) (etodolac, meloxicam, celecoxib, rofecoxib, etoricoxib, valdecoxib and lumiracoxib) for osteoarthritis (OA) and rheumatoid arthritis (RA). DATA SOURCES Electronic databases were searched up to November 2003. Industry submissions to the National Institute for Health and Clinical Excellence (NICE) in 2003 were also reviewed. REVIEW METHODS Systematic reviews of randomised controlled trials (RCTs) and a model-based economic evaluation were undertaken. Meta-analyses were undertaken for each COX-2 selective NSAID compared with placebo and non-selective NSAIDs. The model was designed to run in two forms: the 'full Assessment Group Model (AGM)', which includes an initial drug switching cycle, and the 'simpler AGM', where there is no initial cycle and no opportunity for the patient to switch NSAID. RESULTS Compared with non-selective NSAIDs, the COX-2 selective NSAIDs were found to be equally as efficacious as the non-selective NSAIDs (although meloxicam was found to be of inferior or equivalent efficacy) and also to be associated with significantly fewer clinical upper gastrointestinal (UGI) events (although relatively small numbers of clinical gastrointestinal (GI) and myocardial infarction (MI) events were reported across trials). Subgroup analyses of clinical and complicated UGI events and MI events in relation to aspirin use, steroid use, prior GI history and Helicobacter pylori status were based on relatively small numbers and were inconclusive. In the RCTs that included direct COX-2 comparisons, the drugs were equally tolerated and of equal efficacy. Trials were of insufficient size and duration to allow comparison of risk of clinical UGI events, complicated UGI events and MIs. One RCT compared COX-2 (celecoxib) with a non-selective NSAID combined with a gastroprotective agent (diclofenac combined with omeprazole); this included arthritis patients who had recently suffered a GI haemorrhage. Although no significant difference in clinical GI events was reported, the number of events was small and more such studies, where patients genuinely need NSAIDs, are required to confirm these data. A second trial showed that rofecoxib was associated with fewer diarrhoea events than a combination of diclofenac and misoprostol (Arthrotec). Previously published cost-effectiveness analyses indicated a wide of range of possible incremental cost per quality-adjusted life-year (QALY) gained estimates. Using the simpler AGM, with ibuprofen or diclofenac alone as the comparator, all of the COX-2 products are associated with higher costs (i.e. positive incremental costs) and small increases in effectiveness (i.e. positive incremental effectiveness), measured in terms of QALYs. The magnitude of the incremental costs and the incremental effects, and therefore the incremental cost-effectiveness ratios, vary considerably across all COX-2 selective NSAIDs. The base-case incremental cost per QALY results for COX-2 selective NSAIDs compared with diclofenac for the simpler model are: celecoxib (low dose) 68,400 pounds; celecoxib (high dose) 151,000 pounds; etodolac (branded) 42,400 pounds; etodolac (generic) 17,700 pounds; etoricoxib 31,300 pounds; lumiracoxib 70,400 pounds; meloxicam (low dose) 10,300 pounds; meloxicam (high dose) 17,800 pounds; rofecoxib 97,400 pounds; and valdecoxib 35,500 pounds. When the simpler AGM was run using ibuprofen or diclofenac combined with proton pump inhibitor (PPI) as the comparator, the results change substantially, with the COX-2 selective NSAIDs looking generally unattractive from a cost-effectiveness point of view (COX-2 selective NSAIDs were dominated by ibuprofen or diclofenac combined with PPI in most cases). This applies both to 'standard' and 'high-risk' arthritis patients defined in terms of previous GI ulcers. The full AGM produced results broadly in line with the simpler model. CONCLUSIONS The COX-2 selective NSAIDs examined were found to be similar to non-selective NSAIDs for the symptomatic relief of RA and OA and to provide superior GI tolerability (the majority of evidence is in patients with OA). Although COX-2 selective NSAIDs offer protection against serious GI events, the amount of evidence for this protective effect varied considerably across individual drugs. The volume of trial evidence with regard to cardiovascular safety also varied substantially between COX-2 selective NSAIDs. Increased risk of MI compared to non-selective NSAIDs was observed among those drugs with greater volume of evidence in terms of exposure in patient-years. Economic modelling shows a wide range of possible costs per QALY gained in patients with OA and RA. Costs per QALY also varied if individual drugs were used in 'standard' or 'high'-risk patients, the choice of non-selective NSAID comparator and whether that NSAID was combined with a PPI. With reduced costs of PPIs, future primary research needs to compare the effectiveness and cost-effectiveness of COX-2 selective NSAIDs relative to non-selective NSAIDs with a PPI. Direct comparisons of different COX-2 selective NSAIDs, using equivalent doses, that compare GI and MI risk are needed. Pragmatic studies that include a wider range of people, including the older age groups with a greater burden of arthritis, are also necessary to inform clinical practice.
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Affiliation(s)
- Y-F Chen
- Department of Public Health and Epidemiology, University of Birmingham, UK
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Poller L, Keown M, Ibrahim S, Lowe G, Moia M, Turpie AG, Roberts C, van den Besselaar AMHP, van der Meer FJM, Tripodi A, Palareti G, Shiach C, Bryan S, Samama M, Burgess-Wilson M, Heagerty A, Maccallum P, Wright D, Jespersen J. An international multicenter randomized study of computer-assisted oral anticoagulant dosage vs. medical staff dosage. J Thromb Haemost 2008; 6:935-43. [PMID: 18489430 DOI: 10.1111/j.1538-7836.2008.02959.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Increased demand for oral anticoagulants is overwhelming facilities worldwide, resulting in increasing use of computer assistance. A multicenter clinical endpoint study has been performed to compare the safety and effectiveness of computer-assisted dosage with dosage by experienced medical staff at the same centers. METHODS A randomized study of dosage of two commercial computer-assisted dosage programs (PARMA 5 and DAWN AC) vs. manual dosage at 32 centers with an established interest in oral anticoagulation in 13 countries. The aim was to recruit a minimum of 16,000 patient-years randomized to medical staff or computer-assisted dosage. In total, 13,219 patients participated, 6503 patients being randomized to medical staff and 6716 to computer-assisted dosage. The safety and effectiveness of computer-assisted dosage were compared with those of medical staff dosage. RESULTS In total, 13,052 patients were recruited (18,617 patient-years). International Normalized Ratio (INR) tests numbered 193 890 with manual dosage and 193,424 with computer-assisted dosage. The number of clinical events with computer-assisted dosage was lower (P = 0.1), but in the 3209 patients with deep vein thrombosis/pulmonary embolism, they were reduced by 37 (24%, P = 0.001). Time in target INR range was significantly improved by computer assistance as compared with medical staff dosage at the majority of centers (P < 0.001). CONCLUSIONS The safety and effectiveness of computer-assisted dosage has been demonstrated using two different marketed programs in comparison with experienced medical staff dosage at the centers with established interest in anticoagulation. Significant prevention of clinical events in patients with deep vein thrombosis/pulmonary embolism and the achievement of target INR in all clinical groups has been observed. The reliability and safety of other marketed computer-assisted dosage programs need to be established.
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Affiliation(s)
- L Poller
- EAA Central Facility, Faculty of Life Sciences, University of Manchester, Manchester, UK.
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Williams I, McIver S, Moore D, Bryan S. The use of economic evaluations in NHS decision-making: a review and empirical investigation. Health Technol Assess 2008; 12:iii, ix-x, 1-175. [DOI: 10.3310/hta12070] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | | | - S Bryan
- Health Economics Facility, University of Birmingham, UK
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Khalili J, Karandish S, Bryan S, Molldrem J, McMannis J, Komanduri K. 355: GCSF Decreases CD4+CD25+CD127lo Regulatory T Cell Proliferation Index in Stem Cell Donors. Biol Blood Marrow Transplant 2008. [DOI: 10.1016/j.bbmt.2007.12.365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Vives I Batlle J, Bryan S, McDonald P. A process-based model for the partitioning of soluble, suspended particulate and bed sediment fractions of plutonium and caesium in the eastern Irish Sea. J Environ Radioact 2008; 99:62-80. [PMID: 17719705 DOI: 10.1016/j.jenvrad.2007.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Revised: 06/21/2007] [Accepted: 06/27/2007] [Indexed: 05/16/2023]
Abstract
A dynamic model of plutonium behaviour in the marine environment has been developed, representing the oxidation state distribution and partitioning of plutonium between the soluble, colloidal, suspended particulate and seabed sediment fractions. With simple re-parameterisation, this model can also be applied to (137)Cs. The model, which is calibrated and validated against field data, has been used to predict concentrations of Pu(alpha) and (137)Cs in both water and seabed sediments from the vicinity of the Sellafield Ltd. reprocessing plant in Cumbria, UK. The model predicts that sediment reworking and transport are the key environmental processes as the Sellafield Pu(alpha) and (137)Cs discharge continues to decline. Inventory calculations generated by the model are consistent with previous estimations. For a hypothetical post-discharge scenario, the concentrations of these radionuclides in both seawater and surface sediments are predicted to decrease sharply, concurrent with a downward vertical migration of the activity retained in sediments.
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Affiliation(s)
- J Vives I Batlle
- Westlakes Scientific Consulting Ltd, The Princess Royal Building, Westlakes Science & Technology Park, Moor Row, Cumbria CA24 3LN, UK.
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Fitzmaurice DA, Hobbs FDR, Jowett S, Mant J, Murray ET, Holder R, Raftery JP, Bryan S, Davies M, Lip GYH, Allan TF. Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial. BMJ 2007; 335:383. [PMID: 17673732 PMCID: PMC1952508 DOI: 10.1136/bmj.39280.660567.55] [Citation(s) in RCA: 274] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To assess whether screening improves the detection of atrial fibrillation (cluster randomisation) and to compare systematic and opportunistic screening. DESIGN Multicentred cluster randomised controlled trial, with subsidiary trial embedded within the intervention arm. SETTING 50 primary care centres in England, with further individual randomisation of patients in the intervention practices. PARTICIPANTS 14,802 patients aged 65 or over in 25 intervention and 25 control practices. INTERVENTIONS Patients in intervention practices were randomly allocated to systematic screening (invitation for electrocardiography) or opportunistic screening (pulse taking and invitation for electrocardiography if the pulse was irregular). Screening took place over 12 months in each practice from October 2001 to February 2003. No active screening took place in control practices. MAIN OUTCOME MEASURE Newly identified atrial fibrillation. RESULTS The detection rate of new cases of atrial fibrillation was 1.63% a year in the intervention practices and 1.04% in control practices (difference 0.59%, 95% confidence interval 0.20% to 0.98%). Systematic and opportunistic screening detected similar numbers of new cases (1.62% v 1.64%, difference 0.02%, -0.5% to 0.5%). CONCLUSION Active screening for atrial fibrillation detects additional cases over current practice. The preferred method of screening in patients aged 65 or over in primary care is opportunistic pulse taking with follow-up electrocardiography. TRIAL REGISTRATION Current Controlled Trials ISRCTN19633732 [controlled-trials.com].
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Affiliation(s)
- David A Fitzmaurice
- Department of Primary Care and General Practice, University of Birmingham, Birmingham B15 2TT
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Poller L, Keown M, Ibrahim S, van den Besselaar A, Bryan S, van der Meer F, Palareti G, Roberts C, Shiach C, Tripodi A, Jespersen J, Lowe G. COST-EFFECTIVENESS OF COMPUTER-ASSISTED ANTICOAGULANT DOSAGE CLINICAL STUDY. J Thromb Haemost 2007. [DOI: 10.1111/j.1538-7836.2007.tb01711.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Chen YF, Jobanputra P, Barton P, Jowett S, Bryan S, Clark W, Fry-Smith A, Burls A. A systematic review of the effectiveness of adalimumab, etanercept and infliximab for the treatment of rheumatoid arthritis in adults and an economic evaluation of their cost-effectiveness. Health Technol Assess 2007; 10:iii-iv, xi-xiii, 1-229. [PMID: 17049139 DOI: 10.3310/hta10420] [Citation(s) in RCA: 249] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES This report reviews the clinical effectiveness and cost-effectiveness of adalimumab, etanercept and infliximab, agents that inhibit tumour necrosis factor-alpha (TNF-alpha), when used in the treatment of rheumatoid arthritis (RA) in adults. DATA SOURCES Electronic databases were searched up to February 2005. REVIEW METHODS Systematic reviews of the literature on effectiveness and cost-effectiveness were undertaken and industry submissions to the National Institute for Health and Clinical Excellence (NICE) were reviewed. Meta-analyses of effectiveness data were also undertaken for each agent. The Birmingham Rheumatoid Arthritis Model (BRAM), a simulation model, was further developed and used to produce an incremental cost-effectiveness analysis. RESULTS Twenty-nine randomised controlled trials (RCTs), most of high quality, were included. The only head-to-head comparisons were against methotrexate. For patients with short disease duration (<or=3 years) who were naïve to methotrexate, adalimumab was marginally less and etanercept was marginally more effective than methotrexate in reducing symptoms of RA. Etanercept was better tolerated than methotrexate. Both adalimumab and etanercept were more effective than methotrexate in slowing radiographic joint damage. Etanercept was also marginally more effective and better tolerated than methotrexate in patients with longer disease durations who had not failed methotrexate treatment. Infliximab is only licensed for use with methotrexate. All three agents, either alone (where so licensed) or in combination with ongoing disease-modifying antirheumatic drugs (DMARDs), were effective in reducing the symptoms and signs of RA in patients with established disease. At the licensed dose, the numbers needed to treat (NNTs) (95% CI) required to produce an American College for Rheumatology (ACR) response compared with placebo were: ACR20: adalimumab 3.6 (3.1 to 4.2), etanercept 2.1 (1.9 to 2.4), infliximab 3.2 (2.7 to 4.0); ACR50: adalimumab 4.2 (3.7 to 5.0), etanercept 3.1 (2.7 to 3.6), infliximab 5.0 (3.8 to 6.7); and ACR70: adalimumab 7.7 (5.9 to 11.1), etanercept 7.7 (6.3 to 10.0), infliximab 11.1 (7.7 to 20.0). In patients who were naïve to methotrexate, or who had not previously failed methotrexate treatment, a TNF inhibitor combined with methotrexate was significantly more effective than methotrexate alone. Infliximab combined with methotrexate had an increased risk of serious infections. All ten published economic evaluations met standard criteria for quality, but the incremental cost-effectiveness ratios (ICERs) ranged from being within established thresholds to being very high because of varying assumptions and parameters. All three sponsors who submitted economic models made assumptions favourable to their product. BRAM incorporates improvements in quality of life and mortality, but assumes no effect of TNF inhibitors on joint replacement. For use in accordance with current NICE guidance as the third DMARD in a sequence of DMARDs, the base-case ICER was around pound30,000 per quality-adjusted life-year (QALY) in early RA and pound50,000 per QALY in late RA. Sensitivity analyses showed that the results were sensitive to the estimates of Health Assessment Questionnaire (HAQ) progression while on TNF inhibitors and the effectiveness of DMARDs, but not to changes in mortality ratios per unit HAQ. TNF inhibitors are most cost-effective when used last. The ICER for etanercept used last is pound24,000 per QALY, substantially lower than for adalimumab ( pound30,000 per QALY) or infliximab ( pound38,000 per QALY). First line use as monotherapy generates ICERs around pound50,000 per QALY for adalimumab and etanercept. Using the combination of methotrexate and a TNF inhibitor as first line treatment generates much higher ICERs, as it precludes subsequent use of methotrexate, which is cheap. The ICERs for sequential use are of the same order as using the TNF inhibitor alone. CONCLUSIONS Adalimumab, etanercept and infliximab are effective treatments compared with placebo for RA patients who are not well controlled by conventional DMARDs, improving control of symptoms, improving physical function, and slowing radiographic changes in joints. The combination of a TNF inhibitor with methotrexate was more effective than methotrexate alone in early RA, although the clinical relevance of this additional benefit is yet to be established, particularly in view of the well-established effectiveness of MTX alone. An increased risk of serious infection cannot be ruled out for the combination of methotrexate with adalimumab or infliximab. The results of the economic evaluation based on BRAM are consistent with the observations from the review of clinical effectiveness, including the ranking of treatments. TNF inhibitors are most cost-effective when used as last active therapy. In this analysis, other things being equal, etanercept may be the TNF inhibitor of choice, although this may also depend on patient preference as to route of administration. The next most cost-effective use of TNF inhibitors is third line, as recommended in the 2002 NICE guidance. Direct comparative RCTs of TNF inhibitors against each other and against other DMARDs, and sequential use in patients who have failed a previous TNF inhibitor, are needed. Longer term studies of the quality of life in patients with RA and the impact of DMARDs on this are needed, as are longer studies that directly assess effects on joint replacement, other morbidity and mortality.
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Affiliation(s)
- Y-F Chen
- West Midlands Health Technology Assessment Collaboration (WMHTAC), Department of Public Health and Epidemiology, University of Birmingham, UK
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Courtenay O, Reilly L, Sweeney F, Hibberd V, Bryan S, Ul-Hassan A, Newman C, Macdonald D, Delahay R, Wilson G, Wellington E. Is Mycobacterium bovis in the environment important for the persistence of bovine tuberculosis? Biol Lett 2007; 2:460-2. [PMID: 17148430 PMCID: PMC1686208 DOI: 10.1098/rsbl.2006.0468] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Mycobacterium bovis is the causative agent of bovine tuberculosis (bTB) in cattle and wildlife. Direct aerosol contact is thought to be the primary route of infection between conspecifics, whereas indirect transmission via an environmental reservoir of M. bovis is generally perceived not to be a significant source for infection. Here, we report on the application of molecular technology (PCR) to quantify the prevalence of M. bovis in the environment and to explore its epidemiological significance. We show that the detectability of viable M. bovis at badger setts and latrines is strongly linked to the frequency of M. bovis excretion by infected badgers, and that putative M. bovis in the environment is prevalent on a large proportion of endemic cattle farms in Britain. These results raise important questions about the role of an environmental reservoir in bTB persistence.
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Affiliation(s)
- O Courtenay
- Ecology & Epidemiology Group, Department of Biological Sciences, University of WarwickCoventry CV4 7AL, UK
- Authors for correspondence () ()
| | - L.A Reilly
- Ecology & Epidemiology Group, Department of Biological Sciences, University of WarwickCoventry CV4 7AL, UK
| | - F.P Sweeney
- Microbiology Group, Department of Biological Sciences, University of WarwickCoventry CV4 7AL, UK
| | - V Hibberd
- Microbiology Group, Department of Biological Sciences, University of WarwickCoventry CV4 7AL, UK
| | - S Bryan
- Microbiology Group, Department of Biological Sciences, University of WarwickCoventry CV4 7AL, UK
| | - A Ul-Hassan
- Microbiology Group, Department of Biological Sciences, University of WarwickCoventry CV4 7AL, UK
| | - C Newman
- Wildlife Conservation Research Unit, Department of Zoology, University of OxfordSouth Parks Road, Oxford OX1 3PS, UK
| | - D.W Macdonald
- Wildlife Conservation Research Unit, Department of Zoology, University of OxfordSouth Parks Road, Oxford OX1 3PS, UK
| | - R.J Delahay
- Central Science LaboratorySand Hutton, York YO41 1LZ, UK
| | - G.J Wilson
- Central Science LaboratorySand Hutton, York YO41 1LZ, UK
| | - E.M.H Wellington
- Microbiology Group, Department of Biological Sciences, University of WarwickCoventry CV4 7AL, UK
- Authors for correspondence () ()
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Whitehurst DGT, Lewis M, Yao GL, Bryan S, Raftery JP, Mullis R, Hay EM. A brief pain management program compared with physical therapy for low back pain: Results from an economic analysis alongside a randomized clinical trial. ACTA ACUST UNITED AC 2007; 57:466-73. [PMID: 17394176 DOI: 10.1002/art.22606] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Guidelines for the management of acute low back pain in primary care recommend early intervention to address psychosocial risk factors associated with long-term disability. We assessed the cost utility and cost effectiveness of a brief pain management program (BPM) targeting psychosocial factors compared with physical therapy (PT) for primary care patients with low back pain of <12 weeks' duration. METHODS A total of 402 patients were randomly assigned to BPM or PT. We adopted a health care perspective, examining the direct health care costs of low back pain. Outcome measures were quality-adjusted life years (QALYs) and 12-month change scores on the Roland and Morris disability questionnaire. Resource use data related to back pain were collected at 12-month followup. Cost effectiveness was expressed as incremental ratios, with uncertainty assessed using cost-effectiveness planes and acceptability curves. RESULTS There were no statistically significant differences in mean health care costs or outcomes between treatments. PT had marginally greater effectiveness at 12 months, albeit with greater health care costs (BPM 142 pounds, PT 195 pounds). The incremental cost-per-QALY ratio was 2,362 pounds. If the UK National Health Service were willing to pay 10,000 pound per additional QALY, there is only a 17% chance that BPM provides the best value for money. CONCLUSION PT is a cost-effective primary care management strategy for low back pain. However, the absence of a clinically superior treatment program raises the possibility that BPM could provide an additional primary care approach, administered in fewer sessions, allowing patient and doctor preferences to be considered.
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Affiliation(s)
- D G T Whitehurst
- Primary Care Musculoskeletal Research Centre, Keele University, Staffordshire, UK
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Abstract
OBJECTIVES To determine the relationship between expressed preferences for drug treatment to prevent coronary disease and several participant and general practitioner characteristics among patients attending coronary risk screening. DESIGN Face-to-face interviews with patients. At the first interview, a researcher asked participants to imagine six scenarios representing different levels of pretreatment five-year coronary risk. In each case they were asked whether they would choose treatment that would reduce their coronary risk by 30% of pretreatment risk. At the second interview participants were told their coronary risk and asked whether they would choose treatment. Sociodemographic variables were collected to investigate their relationship to patients' treatment preferences. PARTICIPANTS Patients identified as likely to be at high coronary risk were invited to attend for risk screening and to participate in the study. SETTING 13 practices in the West Midlands. RESULTS Participants' preferences varied widely: at the first interview 112 (55.2%) of 203 participants preferred treatment at 3% five-year coronary risk but 31 (15.3%) preferred no treatment even at 30% five-year coronary risk. Age, sex, education and drug treatment history did not affect preferences, but lower social class was associated with preferring treatment at lower risk. Preferences expressed at the second interview were generally consistent with preferences at the first interview (kappa = 0.510, 95% CI 0.380 to 0.639). CONCLUSIONS Patients attending for coronary risk screening express stable preferences for drug treatment to prevent coronary heart disease. Their preferences vary widely and may be associated with social class.
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Affiliation(s)
- T Marshall
- Department of Public Health & Epidemiology, University of Birmingham, Edgbaston, Birmingham, UK.
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Roberts TE, Robinson S, Barton P, Bryan S, Low N. Screening for Chlamydia trachomatis: a systematic review of the economic evaluations and modelling. Sex Transm Infect 2006; 82:193-200; discussion 201. [PMID: 16731666 PMCID: PMC2593085 DOI: 10.1136/sti.2005.017517] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To review systematically and critically, evidence used to derive estimates of costs and cost effectiveness of chlamydia screening. METHODS Systematic review. A search of 11 electronic bibliographic databases from the earliest date available to August 2004 using keywords including chlamydia, pelvic inflammatory disease, economic evaluation, and cost. We included studies of chlamydia screening in males and/or females over 14 years, including studies of diagnostic tests, contact tracing, and treatment as part of a screening programme. Outcomes included cases of chlamydia identified and major outcomes averted. We assessed methodological quality and the modelling approach used. RESULTS Of 713 identified papers we included 57 formal economic evaluations and two cost studies. Most studies found chlamydia screening to be cost effective, partner notification to be an effective adjunct, and testing with nucleic acid amplification tests, and treatment with azithromycin to be cost effective. Methodological problems limited the validity of these findings: most studies used static models that are inappropriate for infectious diseases; restricted outcomes were used as a basis for policy recommendations; and high estimates of the probability of chlamydia associated complications might have overestimated cost effectiveness. Two high quality dynamic modelling studies found opportunistic screening to be cost effective but poor reporting or uncertainty about complication rates make interpretation difficult. CONCLUSION The inappropriate use of static models to study interventions to prevent a communicable disease means that uncertainty remains about whether chlamydia screening programmes are cost effective or not. The results of this review can be used by health service managers in the allocation of resources, and health economists and other researchers who are considering further research in this area.
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Affiliation(s)
- T E Roberts
- Health Economics Facility, HSMC, University of Birmingham, Park House, 40 Edgbaston Park Road, Birmingham B15 2RT, UK.
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Connock M, Frew E, Evans BW, Bryan S, Cummins C, Fry-Smith A, Li Wan Po A, Sandercock J. The clinical effectiveness and cost-effectiveness of newer drugs for children with epilepsy. A systematic review. Health Technol Assess 2006; 10:iii, ix-118. [PMID: 16545206 DOI: 10.3310/hta10070] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To examine the clinical effectiveness and cost-effectiveness of newer antiepileptic drugs (AEDs) for epilepsy in children: gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine, topiramate and vigabatrin. DATA SOURCES Electronic databases. Drug company submissions. REVIEW METHODS For the systematic review of clinical and cost-effectiveness, studies were assessed for inclusion according to predefined criteria. Data extraction and quality assessment were also undertaken. A decision-analytic model was constructed to estimate the cost-effectiveness of the newer agents in children with partial seizures, the only condition where there were sufficient trial data to inform a model. RESULTS The quality of the randomised controlled trial (RCT) data was generally poor. For each of the epilepsy subtypes considered in RCTs identified for this review (partial epilepsy with or without secondary generalisation, Lennox-Gastaut syndrome, infantile spasms, absence epilepsy and benign epilepsy with centrotemporal spikes), there is some evidence from placebo-controlled trials that the newer agents tested are of some value in the treatment of these conditions. Where active controls have been used, the limited evidence available does not indicate a difference in effectiveness between newer and older drugs. The data are not sufficient to inform a prescribing strategy for any of the newer agents in any of these conditions. In particular, there is no clinical evidence to suggest that the newer agents should be considered as a first-choice treatment in any form of epilepsy in children. Annual drug costs of the newer agents ranges from around 400 pound to 1200 pound, depending on age and concomitant medications. An AED that is ineffective or has intolerable side-effects will only be used for a short period of time, and many patients achieving seizure freedom will successfully withdraw from drug treatment without relapsing. The results of the decision-analytic model do not suggest that the use of the newer agents in any of the scenarios considered is clearly cost-effective but, similarly, do not indicate that they are clearly not cost-effective. CONCLUSIONS The prognosis for children diagnosed with epilepsy is generally good, with a large proportion responding well to the first treatment given. A substantial proportion, however, will not respond well to treatment, and for these patients the clinical goal is to find an optimal balance between the benefits and side-effects of any treatment given. For the newly, or recently, diagnosed population, the key question for the newer drugs is how soon they should be tried. The cost-effectiveness of using these agents early, in place of one of the older agents, will depend on the effectiveness and tolerability of these agents compared with the older agents; the evidence from the available trial data so far suggests that the newer agents are no more effective but may be somewhat better tolerated than the older agents, and so the cost-effectiveness for early use will depend on the trade-off between effectiveness and tolerability, both in terms of overall (long-term) treatment retention and overall utility associated with effects on seizure rate and side-effects. There are insufficient data available to estimate accurately the nature of this trade off either in terms of long-term treatment retention or utility. Better information is required from RCTs before any rational evidence-based prescribing strategy could be developed. Ideally, RCTs should be conducted from a 'public health' perspective, making relevant comparisons and incorporating outcomes of interest to clinicians and patients, with sufficiently long-term follow-up to determine reliably the clinical utility of different treatments, particularly with respect to treatment retention and the balance between effectiveness and tolerability. RCTs should mirror clinical practice with respect to diagnosis, focusing on defined syndromes or, where no syndrome is identified, on groups defined by specific seizure type(s) and aetiology. Epilepsy in children is a complex disease, with a variety of distinct syndromes and many alternative treatment options and outcomes. Diagnosis-specific decision-analytic models are required; further research may be required to inform parameter values adequately with respect to epidemiology and clinical practice.
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Affiliation(s)
- M Connock
- Department of Public Health and Epidemiology, University of Birmingham, UK
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Hobbs FDR, Fitzmaurice DA, Mant J, Murray E, Jowett S, Bryan S, Raftery J, Davies M, Lip G. A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study. Health Technol Assess 2005; 9:iii-iv, ix-x, 1-74. [PMID: 16202350 DOI: 10.3310/hta9400] [Citation(s) in RCA: 259] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To determine the most cost-effective method of screening for atrial fibrillation (AF) in the population aged 65 years and over, as well as its prevalence and incidence in this age group. Also to evaluate the relative cost-effectiveness of different methods of recording and interpreting the electrocardiogram (ECG) within a screening programme. DESIGN Multicentred randomised controlled trial. Purposefully selected general practices were randomly allocated to 25 intervention practices and 25 control practices. SETTING Fifty primary care centres across the West Midlands, UK. PARTICIPANTS Patients aged 65 years and over. INTERVENTIONS GPs and practice nurses in the intervention practices received education on the importance of AF detection and ECG interpretation. Patients in the intervention practices were randomly allocated to systematic (n = 5000) or opportunistic screening (n = 5000). Prospective identification of pre-existing risk factors for AF within the screened population enabled comparison between targeted screening of people at higher risk of AF and total population screening. MAIN OUTCOME MEASURES AF detection rates in systematically screened and opportunistically screened populations in the intervention practices were compared with AF detection rate in 5000 patients in the control practices. The screening period was 12 months. RESULTS Baseline prevalence of AF was 7.2%, with a higher prevalence in males (7.8%) and patients aged 75 years and over (10.3%). The control population demonstrated higher baseline prevalence (7.9%) than either the systematic (6.9%) or opportunistic (6.9%) intervention population. In the control population 47 new cases were detected (incidence 1.04% per year). In the opportunistic arm 243 patients without a baseline diagnosis of AF were found to have an irregular pulse, with 177 having an ECG, yielding 31 new cases (incidence 0.69% per year). A further 44 cases were detected outside the screening programme (overall incidence 1.64% per year). In the systematic arm 2357 patients had an ECG yielding 52 new cases (incidence 1.1% per year). Of these, 31 were detected by targeted screening and a further 21 by total population screening. A further 22 cases were detected outside the screening programme (overall incidence 1.62% per year). In terms of ECG interpretation, computerised decision support software (CDSS) gave a sensitivity of 87.3%, a specificity of 99.1% and a positive predictive value (PPV) of 89.5% compared with the gold standard (cardiologist reporting). GPs and practice nurses performed less well. The only difference in performance between intervention populations and controls was that practice nurses from the control arm performed less well than with intervention practice nurses on interpretation of limb-lead (PPV 38.8% versus 20.8%) and single-lead (PPV 37.7% versus 24.0%) ECGs. The within-trial economic evaluation results showed the lowest incremental cost to be for the opportunistic arm, with an incremental cost-effectiveness ratio of 337 pounds Sterling for each additional case detected compared to the control arm. Opportunistic screening dominated both more intensive screening strategies. Model-based analyses showed small differences in cost and quality-adjusted life-years for different methods and intensities of screening, but annual opportunistic screening resulted in the lowest number of ischaemic strokes and greatest proportion of cases of AF diagnosed. Probabilistic sensitivity results indicated that there was a probability of approximately 60% that screening from the age of 65 years was cost-effective in both men and women. CONCLUSIONS The results of the study indicated that in terms of a screening programme for atrial fibrillation in patients 65 and over, the only strategy that improved on routine practice was opportunistic screening, model-based analyses indicated that there was a probability of approximately 60% of annual opportunistic screening being cost effective. It is suggested that the following topics are worthy of further investigation: the effect of the implementation of a screening programme for AF on the uptake and maintenance of anticoagulation in patients aged 65 years and over; an evaluation of the role of CDSS in the diagnosis of cardiac arrythmias; the best method for routinely detecting paroxysmal AF; ways of improving healthcare professionals' performance in ECG interpretation; development of a robust economic model to incorporate data on new therapeutic agents for use as thromboprophylactic agents for patients with AF, and an evaluation of the relative risk of stroke for patients with incident as opposed to prevalent AF.
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Affiliation(s)
- F D R Hobbs
- Department of Primary Care and General Practice, University of Birmingham, UK
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Abstract
OBJECTIVES To assess whether blood pressure control in primary care could be improved with the use of patient held targets and self monitoring in a practice setting, and to assess the impact of these on health behaviours, anxiety, prescribed antihypertensive drugs, patients' preferences, and costs. DESIGN Randomised controlled trial. SETTING Eight general practices in south Birmingham. PARTICIPANTS 441 people receiving treatment in primary care for hypertension but not controlled below the target of < 140/85 mm Hg. INTERVENTIONS Patients in the intervention group received treatment targets along with facilities to measure their own blood pressure at their general practice; they were also asked to visit their general practitioner or practice nurse if their blood pressure was repeatedly above the target level. Patients in the control group received usual care (blood pressure monitoring by their practice). PRIMARY OUTCOME change in systolic blood pressure at six months and one year in both intervention and control groups. SECONDARY OUTCOMES change in health behaviours, anxiety, prescribed antihypertensive drugs, patients' preferences of method of blood pressure monitoring, and costs. RESULTS 400 (91%) patients attended follow up at one year. Systolic blood pressure in the intervention group had significantly reduced after six months (mean difference 4.3 mm Hg (95% confidence interval 0.8 mm Hg to 7.9 mm Hg)) but not after one year (mean difference 2.7 mm Hg (- 1.2 mm Hg to 6.6 mm Hg)). No overall difference was found in diastolic blood pressure, anxiety, health behaviours, or number of prescribed drugs. Patients who self monitored lost more weight than controls (as evidenced by a drop in body mass index), rated self monitoring above monitoring by a doctor or nurse, and consulted less often. Overall, self monitoring did not cost significantly more than usual care (251 pounds sterling (437 dollars; 364 euros) (95% confidence interval 233 pounds sterling to 275 pounds sterling) versus 240 pounds sterling (217 pounds sterling to 263 pounds sterling). CONCLUSIONS Practice based self monitoring resulted in small but significant improvements of blood pressure at six months, which were not sustained after a year. Self monitoring was well received by patients, anxiety did not increase, and there was no appreciable additional cost. Practice based self monitoring is feasible and results in blood pressure control that is similar to that in usual care.
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Affiliation(s)
- R J McManus
- Department of Primary Care and General Practice, University of Birmingham, Birmingham B15 2TT.
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Greenfield S, Bryan S, Gill P, Gutridge K, Marshall T. Factors influencing clinicians' decisions to prescribe medication to prevent coronary heart disease. J Clin Pharm Ther 2005; 30:77-84. [PMID: 15659007 DOI: 10.1111/j.1365-2710.2004.00615.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE There are variations between individual clinicians as to the thresholds at which preventive treatment for coronary heart disease (CHD) should commence. Patients' decisions may be influenced by clinicians' recommendations. Free text comments added by respondents to closed questionnaires may identify areas which are of real concern to them about the topic being studied. The study aimed to identify issues voluntarily raised by clinicians surrounding the decision to prescribe preventive treatment for CHD. METHODS An analysis was undertaken of the free text comments made by cardiologists, general practitioners and practice nurses who responded to a closed question postal questionnaire in which they were asked to identify at which level of pretreatment risk they would offer treatment. RESULTS AND DISCUSSION A similar percentage of respondents in each professional group provided free text comments. Clinicians' concerns centred on five main themes around prescribing decisions: the risks and benefits of treatment, the patient's role in treatment decisions, patient characteristics, costs to patients, and costs to the health services. Different issues may be of more concern to some professional groups than others. CONCLUSION In addition to the use of risk assessment tools and guidelines, clinicians' actual prescribing behaviour may be influenced by more subjective factors. Patients at similar risk may receive different advice depending on the individual clinician they consult.
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Affiliation(s)
- S Greenfield
- Department of Primary Care and General Practice, University of Birmingham, Edgbaston, Birmingham, UK.
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Willis BH, Barton P, Pearmain P, Bryan S, Hyde C. Cervical screening programmes: can automation help? Evidence from systematic reviews, an economic analysis and a simulation modelling exercise applied to the UK. Health Technol Assess 2005; 9:1-207, iii. [PMID: 15774236 DOI: 10.3310/hta9130] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To assess the effectiveness and cost-effectiveness of adding automated image analysis to cervical screening programmes. DATA SOURCES Searching of all major electronic databases to the end of 2000 was supplemented by a detailed survey for unpublished UK literature. METHOD Four systematic reviews were conducted according to recognised guidance. The review of 'clinical effectiveness' included studies assessing reproducibility and impact on health outcomes and processes in addition to evaluations of test accuracy. A discrete event simulation model was developed, although the economic evaluation ultimately relied on a cost-minimisation analysis. RESULTS The predominant finding from the systematic reviews was the very limited amount of rigorous primary research. None of the included studies refers to the only commercially available automated image analysis device in 2002, the AutoPap Guided Screening (GS) System. The results of the included studies were debatably most compatible with automated image analysis being equivalent in test performance to manual screening. Concerning process, there was evidence that automation does lead to reductions in average slide processing times. In the PRISMATIC trial this was reduced from 10.4 to 3.9 minutes, a statistically significant and practically important difference. The economic evaluation tentatively suggested that the AutoPap GS System may be efficient. The key proviso is that credible data become available to support that the AutoPap GS System has test performance and processing times equivalent to those obtained for PAPNET. CONCLUSIONS The available evidence is still insufficient to recommend implementation of automated image analysis systems. The priority for action remains further research, particularly the 'clinical effectiveness' of the AutoPap GS System. Assessing the cost-effectiveness of introducing automation alongside other approaches is also a priority.
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Affiliation(s)
- B H Willis
- ARIF, Department of Public Health and Epidemiology, University of Birmingham, UK
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Rotermann M, Bryan S, Tremblay MS. 016: Seasonal Variation Among the 5 Most Popular Leisure-Time Physical Activities in Canada. Am J Epidemiol 2005. [DOI: 10.1093/aje/161.supplement_1.s4c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - S Bryan
- Statistics Canada, Ottawa, Canada
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Abstract
There are measurement difficulties associated with the assessment of health-related quality of life (HRQL) in older people with dementia. The use of proxies is a commonly employed approach to overcome such problems. The research reported in this paper sought to identify, specifically for the EuroQol EQ-5D HRQL instrument, whether construct validity is greater for 'family caregivers' or 'clinicians' as two alternative sources of proxy information for patients with a diagnosis of dementia. This involved the exploration of the strength of the associations between clinical measures of illness severity and EQ-5D data. The data appear to reveal a pattern suggesting that the viewpoint of the proxy (i.e., clinician or family caregiver) is important. The findings suggest that the data provided by clinicians (when compared to data from carers) had higher construct validity for the more observable dimensions of the EQ-5D instrument (i.e., 'mobility' and 'self-care'). Conversely, the data from family carers had higher construct validity for the less observable dimensions (i.e., 'usual activities' and 'anxiety/depression'). Previous research on proxy provision of HRQL data has tended to focus on trying to identify a single proxy. The results of this study suggest that using carefully matched sets of measures and assessment perspectives may produce more valid EQ-5D health state descriptions.
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Affiliation(s)
- S Bryan
- Health Economics Facility, Health Services Management Centre, University of Birmingham, Birmingham, UK.
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