Economic evaluation of the Very Early Rehabilitation in SpEech (VERSE) intervention.

INTRODUCTION: There is limited evidence on the costs and outcomes of patients with aphasia after stroke. The aim of this study was to estimate costs in patients with aphasia after stroke according to the aphasia therapies provided. METHODS: A three-arm, prospective, randomized, parallel group, open-label, blinded endpoint assessment trial conducted in Australia and New Zealand. Usual ward-based care (Usual Care) was compared to additional usual ward-based therapy (Usual Care Plus) and a prescribed and structured aphasia therapy program in addition to Usual Care (the VERSE intervention). Information about healthcare utilization and productivity were collected to estimate costs in Australian dollars for 2017-18. Multivariable regression models with bootstrapping were used to estimate differences in costs and outcomes (clinically meaningful change in aphasia severity measured by the WAB-R-AQ). RESULTS: Overall, 202/246 (82%) participants completed follow-up at 26 weeks. Median costs per person were $23,322 (Q1 5,367, Q3 52,669, n = 63) for Usual Care, $26,923 (Q1 7,303, Q3 76,174, n = 70) for Usual Care Plus and $31,143 (Q1 7,001. Q3 62,390, n = 69) for VERSE. No differences in costs and outcomes were detected between groups. Usual Care Plus was inferior (i.e. more costly and less effective) in 64% of iterations, and in 18% was less costly and less effective compared to Usual Care. VERSE was inferior in 65% of samples and less costly and less effective in 12% compared to Usual Care. CONCLUSION: There was limited evidence that additional intensively delivered aphasia therapy within the context of usual acute care provided was worthwhile in terms of costs for the outcomes gained.

Understanding quality of service in family planning in Nepal.

PIP: In 1993, a Family Health International team conducted formative research of two public sector clinics in Kathmandu Valley to expand their understanding of quality of family planning service delivery in Nepal, particularly as it applies to Norplant. Counselors rarely provided information on other suitable contraceptive methods to women requesting removal of Norplant. In fact, they tended to send the clients directly to a physician or a health assistant with no counseling. Counselors often provided clients seeking a particular method only information on that method. Overall, they spent no more than five minutes discussing methods with each client. Most of their time involved documenting the client's background. Counseling sessions were not conducted in privacy. Providers tended to be insensitive to clients' needs for privacy, e.g., during pelvic exams. Counselors were reluctant or embarrassed to explain how to use condoms. A sterile environment was not always maintained when performing medical procedures. For example, staff sometimes did not wear masks in the operating room. Re-use of needles and knife blades made them dull, making it hard to pierce or cut the client's skin. Sufficient time was not always allowed for the anesthesia to take effect before beginning to implant the Norplant capsules. Side effects were the main reasons for removal of Norplant. After removal, clients left the clinic with no discussion of follow-up or other contraceptive methods. Clinic staff rarely referred a client with a medical condition (e.g., jaundice) to a physician. The team concluded that most providers know how to do a better job to assure quality delivery of family planning services but tended to be negligent or wanted to save time. It also identified that many of the weaknesses could be eliminated at the clinics without taking more time or requiring more resources.^ieng