Research evaluating the effectiveness of dementia interventions in low- and middle-income countries: A systematic mapping of 340 randomised controlled trials.

OBJECTIVES: More people with dementia live in low- and middle-income countries (LMICs) than in high-income countries, but best-practice care recommendations are often based on studies from high-income countries. We aimed to map the available evidence on dementia interventions in LMICs. METHODS: We systematically mapped available evidence on interventions that aimed to improve the lives of people with dementia or mild cognitive impairment (MCI) and/or their carers in LMICs (registered on PROSPERO: CRD42018106206). We included randomised controlled trials (RCTs) published between 2008 and 2018. We searched 11 electronic academic and grey literature databases (MEDLINE, EMBASE, PsycINFO, CINAHL Plus, Global Health, World Health Organization Global Index Medicus, Virtual Health Library, Cochrane CENTRAL, Social Care Online, BASE, MODEM Toolkit) and examined the number and characteristics of RCTs according to intervention type. We used the Cochrane risk of bias 2.0 tool to assess the risk of bias. RESULTS: We included 340 RCTs with 29,882 (median, 68) participants, published 2008-2018. Over two-thirds of the studies were conducted in China (n = 237, 69.7%). Ten LMICs accounted for 95.9% of included RCTs. The largest category of interventions was Traditional Chinese Medicine (n = 149, 43.8%), followed by Western medicine pharmaceuticals (n = 109, 32.1%), supplements (n = 43, 12.6%), and structured therapeutic psychosocial interventions (n = 37, 10.9%). Overall risk of bias was judged to be high for 201 RCTs (59.1%), moderate for 136 (40.0%), and low for 3 (0.9%). CONCLUSIONS: Evidence-generation on interventions for people with dementia or MCI and/or their carers in LMICs is concentrated in just a few countries, with no RCTs reported in the vast majority of LMICs. The body of evidence is skewed towards selected interventions and overall subject to high risk of bias. There is a need for a more coordinated approach to robust evidence-generation for LMICs.

Cost-effectiveness analysis for SilAtro-5-90 adjuvant treatment in the management of recurrent tonsillitis, compared with usual care only.

PURPOSE: Antibiotics are one possible treatment for patients with recurrent acute throat infections (ATI), but effectiveness can be modest. In view of worries over antibiotic resistance, treatment pathways that reduce recurrence of ATI are essential from a public health perspective. Integrative treatment strategies can be an option but there is still a high demand to provide evidence of their cost effectiveness. METHODS: We constructed a 4-state Markov model to compare the cost-effectiveness of SilAtro-5-90 as adjuvant homeopathic therapy to care as usual with care as usual alone in reducing the recurrence of ATI for children and adults with suspected moderate recurrent tonsillitis. The analysis was performed from a societal perspective in Germany over a 2-year period. Results are reported separately for children < 12 and for individuals aged 12 and over. The model draws on evidence from a multi-centre randomised clinical trial that found this strategy effective in reducing recurrence of ATI. Costs in 2019 € and outcomes after 1 year are discounted at a rate of 3% per annum. RESULTS: For adults and adolescents aged 12 years and over, incremental cost per ATI averted in the adjuvant therapy group was €156.64. If individuals enter the model on average with a history of 3.33 previous ATIs, adjuvant therapy has both lower costs and better outcomes than care as usual. For children (< 12 years) adjuvant therapy had both lower costs and ATI than care as usual. The economic case is stronger if adjuvant treatment reduces surgical referral. At a hypothetical cost per ATI averted threshold of €1000 probabilistic sensitivity analysis suggests Silatro-5-90 has a 65% (adults) and 71% (children) chance of being cost-effective. CONCLUSION: Our results indicate the importance of considering homeopathy as adjuvant therapy in the treatment of ATIs in individuals with recurrent tonsillitis from a socio-economic perspective. Further evaluation should assess how differences in uptake and sustained use of homeopathic adjuvant therapy, as well as changing patterns of antibiotic prescribing, impact on cost effectiveness.

What do we know about the strengths and weakness of different policy mechanisms to influence health behaviour in the population?

With health care systems under increasing pressure the development of a well defined and effective public health strategy has never been more important. Many health problems are potentially avoidable and governments have long had tools at their disposal to influence population health and change individual behaviours, directed both ‘upstream’ at some of the underlying causes of poor health, as well as at ‘downstream’ challenges when poor health behaviours are already manifest. But how effective are these different actions? This policy summary briefly maps out what is known about some of these mechanisms, including approaches that have come to recent prominence from behavioural economics and psychology. Combinations of taxation, legislation and health information remain the core components of any strategy to influence behavioural change. There remain many unanswered questions on how best to design new innovative interventions that can complement, and in some instances augment, these well established mechanisms.

Evaluation of an integrated system for classification, assessment and comparison of services for long-term care in Europe: the eDESDE-LTC study.

BACKGROUND: The harmonization of European health systems brings with it a need for tools to allow the standardized collection of information about medical care. A common coding system and standards for the description of services are needed to allow local data to be incorporated into evidence-informed policy, and to permit equity and mobility to be assessed. The aim of this project has been to design such a classification and a related tool for the coding of services for Long Term Care (DESDE-LTC), based on the European Service Mapping Schedule (ESMS). METHODS: The development of DESDE-LTC followed an iterative process using nominal groups in 6 European countries. 54 researchers and stakeholders in health and social services contributed to this process. In order to classify services, we use the minimal organization unit or "Basic Stable Input of Care" (BSIC), coded by its principal function or "Main Type of Care" (MTC). The evaluation of the tool included an analysis of feasibility, consistency, ontology, inter-rater reliability, Boolean Factor Analysis, and a preliminary impact analysis (screening, scoping and appraisal). RESULTS: DESDE-LTC includes an alpha-numerical coding system, a glossary and an assessment instrument for mapping and counting LTC. It shows high feasibility, consistency, inter-rater reliability and face, content and construct validity. DESDE-LTC is ontologically consistent. It is regarded by experts as useful and relevant for evidence-informed decision making. CONCLUSION: DESDE-LTC contributes to establishing a common terminology, taxonomy and coding of LTC services in a European context, and a standard procedure for data collection and international comparison.

Каким образом телездравоохранение может помочь в предоставлении интегрированной помощи?

Телездравоохранение, или оказание помощи на расстоянии, вне всякого сомнения, станет одной из ключевых составляющих в будущейинформационно-коммуникационной инфраструктуре, необходимой для организации интегрированной помощи. Лица, формирующие политику, уже сейчас возлагают на него большие надежды, рассматривая его как возможный способ решения обостряющихся проблем кадров. Для того,чтобы обеспечить интегрированность помощи, необходимо включить обособленные сегодня прикладные задачи, решаемые с помощьютелездравоохранения, в более комплексные стратегии электронного здравоохранения, в которых были бы предусмотрены полная координация протоколов ведения больных и процессов оказания услуг и безопасный обмен данными о пациентах. Несмотря на то, что пока в Европе и в других регионах имеется мало примеров применения телездравоохранения в порядке повседневнойпрактики (в противоположность огромному объему исследований в этой области), формируется база все более убедительных фактических данных, свидетельствующих о том, что телездравоохранение можно успешноиспользовать для того, чтобы помочь обеспечить более высокое качество интегрированной помощи, в частности, тем, кто страдает продолжительными хроническими заболеваниями.

How can telehealth help in the provision of integrated care?

Telehealth, the provision of care at a distance, is certain to be a key component in future ICT infrastructure for integrated care. It has already raised high hopes among policy-makers with regard to its potential for delivering solutions forgrowing capacity problems. For integrated care, today's segregated telehealth applications still require linking into more comprehensive eHealth strategies, in which clinical pathways and service delivery processes are fully coordinated andpatient data safely shared. Although few instances of routine application have yet emerged in Europe or elsewhere – in contrast with an enormous breadth of research activities – anincreasingly solid evidence base is emerging indicating that telehealth can be used effectively to help support better integrated care, in particular for those with long-term chronic conditions.

Mental health reform in the Russian Federation: an integrated approach to achieve social inclusion and recovery.

OBJECTIVE: To facilitate mental health reform in one Russian oblast (region) using systematic approaches to policy design and implementation. METHODS: The authors undertook a three-year action-research programme across three pilot sites, comprising a multifaceted set of interventions combining situation appraisal to inform planning, sustained policy dialogue at federal and regional levels to catalyse change, introduction of multidisciplinary and intersectoral-working at all levels, skills-based training for professionals, and support for nongovernmental organizations (NGOs) to develop new care models. FINDINGS: Training programmes developed in this process have been adopted into routine curricula with measurable changes in staff skills. Approaches to care improved through multidisciplinary and multisectoral service delivery, with an increase in NGO activities, user involvement in care planning and delivery in all pilot sites. Hospital admissions at start and end of the study fell in two pilot sites, while the rate of readmissions in all three pilot sites by 2006 was below that for the region as a whole. Lessons learned have informed the development of regional and federal mental health policies. CONCLUSION: A multifaceted and comprehensive programme can be effective in overcoming organizational barriers to the introduction of evidence-based multisectoral interventions in one Russian region. This can help facilitate significant and sustainable changes in policy and reduce institutionalization.