RESUMO
QUESTION: Is preoperative physiotherapy cost-effective in reducing postoperative pulmonary complications (PPC) and improving quality-adjusted life years (QALYs) after major abdominal surgery? DESIGN: Cost-effectiveness analysis from the hospitals' perspective within a multicentre randomised controlled trial with concealed allocation, blinded assessors and intention-to-treat analysis. PARTICIPANTS: Four hundred and forty-one adults awaiting elective upper abdominal surgery attending pre-anaesthetic clinics at three public hospitals in Australia and New Zealand. INTERVENTIONS: The experimental group received an information booklet and a 30-minute face-to-face session, involving respiratory education and breathing exercise training, with a physiotherapist. The control group received the information booklet only. OUTCOME MEASURES: The probability of cost-effectiveness and incremental net benefits was estimated using bootstrapped incremental PPC and QALY cost-effectiveness ratios plotted on cost-effectiveness planes and associated probability curves through a range of willingness-to-pay amounts. Cost-effectiveness modelling utilised 21-day postoperative hospital cost audit data and QALYs estimated from Short Form-Six Domain health utilities and mortality to 12 months. RESULTS: Preoperative physiotherapy had 95% probability of being cost-effective with an incremental net benefit to participating hospitals of A$4,958 (95% CI 10 to 9,197) for each PPC prevented, given that the hospitals were willing to pay $45,000 to provide the service. Cost-utility for QALY gains was less certain. Sensitivity analyses strengthened cost-effectiveness findings. Improved cost-effectiveness and QALY gains were detected when experienced physiotherapists delivered the intervention. CONCLUSIONS: Preoperative physiotherapy aimed at preventing PPCs was highly likely to be cost-effective from the hospitals' perspective. For each PPC prevented, preoperative physiotherapy is likely to cost the hospitals less than the costs estimated to treat a PPC after surgery. Potential QALY gains require confirmation. TRIAL REGISTRATION: ACTRN12613000664741.
Assuntos
Abdome/cirurgia , Exercícios Respiratórios/métodos , Pneumopatias/economia , Pneumopatias/prevenção & controle , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/economia , Idoso , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Anos de Vida Ajustados por Qualidade de Vida , Método Simples-CegoRESUMO
BACKGROUND: Post-operative pulmonary complications are a significant problem following open upper abdominal surgery. Preliminary evidence suggests that a single pre-operative physiotherapy education and preparatory lung expansion training session alone may prevent respiratory complications more effectively than supervised post-operative breathing and coughing exercises. However, the evidence is inconclusive due to methodological limitations. No well-designed, adequately powered, randomised controlled trial has investigated the effect of pre-operative education and training on post-operative respiratory complications, hospital length of stay, and health-related quality of life following upper abdominal surgery. METHODS/DESIGN: The Lung Infection Prevention Post Surgery - Major Abdominal- with Pre-Operative Physiotherapy (LIPPSMAck POP) trial is a pragmatic, investigator-initiated, bi-national, multi-centre, patient- and assessor-blinded, parallel group, randomised controlled trial, powered for superiority. Four hundred and forty-one patients scheduled for elective open upper abdominal surgery at two Australian and one New Zealand hospital will be randomised using concealed allocation to receive either i) an information booklet or ii) an information booklet, plus one additional pre-operative physiotherapy education and training session. The primary outcome is respiratory complication incidence using standardised diagnostic criteria. Secondary outcomes include hospital length of stay and costs, pneumonia diagnosis, intensive care unit readmission and length of stay, days/h to mobilise >1 min and >10 min, and, at 6 weeks post-surgery, patient reported complications, health-related quality of life, and physical capacity. DISCUSSION: The LIPPSMAck POP trial is a multi-centre randomised controlled trial powered and designed to investigate whether a single pre-operative physiotherapy session prevents post-operative respiratory complications. This trial standardises post-operative assisted ambulation and physiotherapy, measures many known confounders, and includes a post-discharge follow-up of complication rates, functional capacity, and health-related quality of life. This trial is currently recruiting. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry number: ACTRN12613000664741 , 19 June 2013.
Assuntos
Abdome/cirurgia , Laparotomia/efeitos adversos , Modalidades de Fisioterapia , Cuidados Pré-Operatórios/métodos , Infecções Respiratórias/prevenção & controle , Protocolos Clínicos , Análise Custo-Benefício , Método Duplo-Cego , Procedimentos Cirúrgicos Eletivos , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Custos Hospitalares , Humanos , Laparotomia/economia , Tempo de Internação , Masculino , Nova Zelândia , Folhetos , Educação de Pacientes como Assunto/métodos , Modalidades de Fisioterapia/economia , Cuidados Pré-Operatórios/economia , Qualidade de Vida , Recuperação de Função Fisiológica , Projetos de Pesquisa , Infecções Respiratórias/diagnóstico , Infecções Respiratórias/economia , Infecções Respiratórias/microbiologia , Fatores de Risco , Tasmânia , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: High rates of complementary and alternative medicine (CAM) use are well documented in the general population without clear clinical benefits. Published studies examining prevalence and patterns of CAM use in emergency patients, however, are limited. The objectives of this study were to describe the prevalence and patterns of CAM use in urban ED patients. METHODS: This was a descriptive study of a convenience sample of 174 patients presenting to the emergency department of a level I, urban, Catholic, tertiary teaching center, with an annual ED census of 43,000. RESULTS: CAM use in our study group was high (47%). Although no sociodemographic predictors of CAM users were found, CAM users were more likely to have chronic conditions (P =.044). One third did not disclose CAM use. Prayer (28%), music therapy (11%), and meditation (10%) were the most frequently used types of CAM reported. DISCUSSION: Patients should be questioned routinely about CAM use, given the high rates of use and low disclosure rates. Knowledge of potential positive and negative effects of CAM, interactions with conventional treatments, and sensitivity toward patients' decisions to opt for CAM are imperative. Spiritual support, where available, should be considered for at least some ED patients. The 3 most common types of CAM reported by ED patients at our level I trauma center were prayer/spirituality, music therapy, and meditation.